How pathways are developed:

A steering committee comprised of local rheumatologists contracted with CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. (collectively “CareFirst”) is tasked with creating and updating a pathway for adult patients with Rheumatoid Arthritis (RA). The Committee is co-chaired by Dr. Herbart Baraf and Dr. Alan Matsumoto. The Committee was asked to create a pathway which was designed to treat 90% of adult RA patients with three main rules in the design process: efficacy; safety; and if these are equal, consideration of cost.

Compliance:

The pathway is not designed to cover 100% of RA therapies, and the physician has the ultimate choice in the patients’ care. Thus, compliance for the first year is set at 70%, and at 80% compliance for all following years. Open enrollment will occur from 10/1/2011 to 11/30/2011. There will be two enrollment dates in 2012: 3/1/2012 and 9/1/2012. There will be a one month lag time between enrollment and effective date in the program. For physicians that sign up on 10/1/2011, patients with a date of service on or after 11/1/2011 will be effective in the program. For physicians that enroll during this open enrollment phase, compliance in the program will be based on either the final quarter of 2012 or that physician’s cumulative compliance from the enrollment date to the end of 2012. Practices with 70% compliance during either period will continue in the program. To ensure an adequate sample size, CareFirst requires a physician to enroll at least 10 CareFirst RA patients before making a compliance judgment.

Compliance measurement, CDAI collection tool and eobONE:

One of the most important parts of the pathway is the inclusion of a disease progression score, CDAI. To facilitate collection of this score, P4 Pathways parent company, Cardinal Health, has designed a simple tablet-based information collection tool which interacts with the patient and physician. The information collected will yield a CDAI score, along with the capture of basic drug therapies chosen. The tool is designed to be patient and physician friendly and is anticipated to have minimal impact on the patient flow. Given that it is strongly recommended for inclusion into the program, the tool will be installed in your practice at no cost to you. If installation of the tool is impossible given extenuating practice circumstances, fax and internet based forms will be provided as an alternate option. Coupled with our partner claims analysis tool, eobONE (see eobONE white paper), the toolset enables P4 Pathways to capture everything we need in order to accurately monitor compliance to the chosen pathway.

Compliance Website:

Physicians and practice administrators can gain a copy of the pathway, and view historical compliance scores on a secure, HIPAA compliant, website. If our systems mark a patient as non-compliant when there is a legitimate pathway reason for a treatment decision, the physicians can log into the website to reconcile non-compliant patients.

Prior Authorization:

As an added benefit to the P4 RA Pathways program, the prior authorization requirements will be waived for program participants given the request goes through P4 Pathways preferred specialty pharmacy vendor, OncoSourceRx. Subcutaneous requests referred to other pharmacies will be required to go through the standard prior authorization review process. CareFirst BCBS and P4 Pathways are excited to bring you this Gold Card benefit as a participant in the RA Pathways program. The gold card process through OncoSourceRx will prove to eliminate the administrative burden by the practice of procuring prior authorizations.

Please contact Mikesh Patel with any questions regarding the program: mikesh.patel@cardinalhealth.com
Office: 443.518.7018