Value-based drug purchasing, better coordination of care delivery, and earlier institution of palliative care were among the measures to lower the cost of cancer care that were suggested during a panel discussion at the 2020 virtual National Comprehensive Cancer Network (NCCN) Oncology Policy Summit. The discussion was moderated by Clifford Goodman, PhD, Senior Vice President, Comparative Effectiveness Research, The Lewin Group.
High Drug Cost
Too often, cancer drugs receive FDA approval that have minimal benefit for patients who should receive palliative care, said Ruth O’Regan, MD, Division Head, Hematology and Oncology, University of Wisconsin Carbone Cancer Center, Madison. She cited the expense of oncology drugs as a large contributor to the high cost of care.
“Drug cost would be one of the most important issues, but also access to care, and making sure that all of our population have equal access to oncology care, including drugs and procedures,” Dr O’Regan said.
Angela Mysliwiec, MD, Senior Medical Director, WellMed Medical Group, argued that more collaboration between care delivery organizations and health benefits plans can help keep patients out of the hospital and lower the total cost of care. Using guidelines-based therapy would serve the same purpose.
To manage drug costs, a prior authorization process has been established at WellMed, in which all requests for chemotherapy are viewed against the NCCN guidelines, said Dr Mysliwiec.
“If it doesn’t meet guidelines, we will go further to check and see if it meets the off-label use for any medication,” she said. “We also have a dose-optimization program whereby any waste is hopefully reduced. We also do a comprehensive medication review, such that toxicities are assessed for that patient compared to another medication they may be on.”
Once a drug is selected, ensuring that the patient receives the greatest benefit at the lowest cost is paramount, said Gena Cook, Founder and President, Navigating Cancer, Seattle, WA. “One of the areas that we’ve been focusing on is automating and creating a faster process for triage and telehealth, and using symptom management pathways or guidelines,” she said.
“What we’ve proved is that we were able to become more efficient and to provide faster interventions to patients, which has been proved to reduce emergency department visits and hospitalizations to lower the cost of healthcare. And to ensure that patients receive coordinated, validated, quality care in a consistent manner,” Ms Cook added. Considering care as a continuum, from choosing the best agent, to providing patients the resources to keep them out of the hospital, to improved palliative care can all present opportunities for cost-savings, she suggested.
Ted Okon, MBA, Executive Director, Community Oncology Alliance, said that high drug costs are fueled by drug discounts and rebates, a portion of which are kept by “middlemen,” such as pharmacy benefits managers (PBMs). The pricing pressure extracted by PBMs does not find its way to the payer or the patient, he said. In addition, manufacturers consider discounts when pricing their therapies.
Moving to value-based pricing arrangements on the drug side, including the incorporation of biosimilars, is necessary to bend the cost curve in cancer care, he believes. Rebates, however, hamper the ability to reduce cost by impeding the uptake of biosimilars, Mr Okon claimed. Single-source drugs (ie, those without competition) may require government price fixing to reduce their cost, although free market advocates claim that price fixing “never works,” he said.
“When you see aggressive low pricing in other countries, it’s because those countries negotiate drug process,” Mr Okon said. “I’m not giving that an endorsement, but the bottom line is, that’s what they do from a societal standpoint.” He noted that government price fixing would make fewer drugs available; he therefore prefers value-based pricing.
The panelists agreed that the proposed rule by the Centers for Medicare & Medicaid Services that promotes value-based purchasing for Medicaid-covered drugs is a step in the right direction. Currently, under the Medicaid Drug Rebate Program (MDRP), drug manufacturers must sell their drugs to Medicaid programs at the lowest price available to any wholesaler, retailer, or provider, or the manufacturer’s “best price.”
The best price requirement was called an obstacle to outcomes-based value-based purchasing, in which a drug’s price is linked to clinical performance. The proposed rule would modify the MDRP requirement to allow manufacturers to report multiple best prices based on measurable clinical outcomes.