By: John Lechleiter
From: forbes.com
New insights on how progress against cancer unfolds, and on how to meet the challenges of affording high-quality treatment, should make us optimistic that the coming years will bring not only further scientific breakthroughs against cancer but also much-needed policy breakthroughs in the development, financing, and delivery of excellent cancer care.
If you’ve only been following controversies on the cost of cancer care, then you may be scratching your head at my assessment. Many call the economic burden of cancer care in the U.S., expected to reach more than $170 billion per year by 2020, “unsustainable.” Expensive medicines are the culprits, we are told, delivering little value. And the possible outcomes consist either of growing disparities in access to high-quality care, or of price controls on medicines and the resultant throttling of innovation.
Yet when you lift this veil of conventional wisdom, the actual view to the future looks noticeably brighter.
First, evidence and experience show that the conventional wisdom is misleading or simply wrong. Spending on the treatment of cancer as a share of overall healthcare expenditures in the U.S. has not changed significantly in 50 years; in 1963 it was 4.4% and in 2010 it was 4.8%—evidence not of “unsustainability” but of relative efficiency when you consider that the incidence of cancer increased dramatically over that same period. And cancer medicines represent one of the smallest and most stable components, accounting for about 20% of cancer-care expenditures, or about 1% of overall U.S. healthcare spending.
Meanwhile, as I’ve noted before in this space, a recent study from the front lines of U.S. cancer care suggests that critics may be over-emphasizing the importance of drug costs while missing opportunities to incentivize reductions in overall treatment costs. United Healthcare (UHC) compared the cost of cancer care in the long-standing “fee-for-service” model—in which doctors are reimbursed in part based on the number of cancer medicines and other services they prescribe—with five groups of doctors reimbursed at flat rates for adhering to strict quality measures. Defying conventional wisdom, the doctors motivated by quality prescribed more cancer medicines—resulting in a higher bill for drugs—while the overall costs of care for their patients plummeted by a third as compared with the conventional model.
At the same time, efforts to try to score the value of cancer medicines appear to be opening people’s eyes to the complexity of defining value and the importance of keeping patients at the center of decision making. I’ve been a skeptic about attempts by the American Society of Clinical Oncology (ASCO) and others to develop value algorithms—believing that efforts to rate treatments at launch and without reference to the needs of individual patients are inherently flawed. But the discussion generated by these efforts has been constructive.
To contribute to the discussion, over the last several years, my own company spearheaded the creation of a massive database and analysis tool—called the PACE Continuous Innovation Indicators™ or “CII”—which we launched last week together with partners from the research and patient-advocacy communities. The CII take a retrospective approach, examining thousands of pieces of evidence for progress against 12 specific cancers across all treatment types. Users can query the database in countless ways and assign their own weights to various kinds of progress. Looking at a number of the outputs, my own conclusion is that progress against cancer has invariably unfolded in a step-wise manner—which means that seemingly small improvements are essential and need to be valued. But the steps are just too slow.
Fortunately, these insights point to some ways forward that could improve treatment and speed innovation.
The UHC pilot highlights the importance of quality measures in reimbursing cancer care. Other reform paths involve transparency about costs, and an emphasis on the needs of individual patients in care and payment models.
At present, cancer medicines are the only component of cancer-care costs open to daylight. The rest of the system needs to be transparent as well—which likely would reduce large variations in the cost of the same services between different cancer-care providers; the confusing array of mandatory government rebates and discounts; and the shift of care from community-based clinics to more expensive hospital settings.
Similarly, it is time to end the long-standing bias against cancer drugs in our commercial insurance models. The average patient co-payment for all prescription medicines is about 22%—and can reach above 30% for so-called “specialty drugs” including some cancer medicines—while it stands at about 17% for doctors’ charges and 4% for in-patient hospital charges. Eliminating this bias would help to control costs elsewhere in the system and leave patients’ remaining out-of-pocket expenses at more manageable levels.
Meanwhile, the pharmaceutical industry needs to grapple with the pricing implications of scientific trends in cancer care. For example, we will need new models for pricing “combination therapies”—the cocktails of treatments that experts believe hold the key to long-term cancer remissions and cures. Simply adding the prices of A, B, and C will not be realistic when the cocktails consist of new, still-branded medicines. For the same reason, we need to be open to figuring out—together with public and private payers—ways of recognizing that a given medicine will not necessarily have the same value against different forms of cancer.
In addition to improving quality and transparency, and reforming insurance and pricing models, another key objective must be to streamline research. The more that we can do to accelerate cancer R&D—and to bring ever-more targeted treatments and effective to patients—the more valuable and cost-effective will be the resulting care.
The PACE CII tool, for example, paints a compelling picture of how the absence of validated biomarkers, slow patient enrollment in clinical trials, and the poor incentive structure for certain kinds of clinical research, along with many other fixable challenges impede the development or identification of more effective cancer treatments.
The U.S. Food and Drug Administration’s oncology division has shown itself to be an open-minded and willing partner with academia and industry in efforts to accelerate cancer R&D—exploring “adaptive” clinical trials that adjust based on what is being learned, for example, as well as industry efforts to steer patients to the most appropriate trials through “master protocol agreements.” Look for much more to come.
Finally, I’m optimistic about these and other policy breakthroughs to improve cancer care because of the diverse coalitions rising up to pursue them. The “21st-Century Cures” and “MODDERN Cures” initiatives in Congress include strong reform ideas with broad, bipartisan support. The “Cancer Innovation Coalition”—spearheaded by the National Patient Advocate Foundation among patient advocates, research groups, and industry—similarly supports a policy agenda emphasizing innovation in cancer-related genomics; faster, more productive clinical research, and greater access and transparency in the provision of care. And the “Turning the Tide Against Cancer” effort last fall released a set of thoughtful policy recommendations to move towards more patient-centered cancer R&D and to address the cost and value issues in cancer care.
With these coalitions working at the grass roots and in Washington to advance a growing reform consensus, there are plenty of reasons to believe that policy breakthroughs will lead to further scientific breakthroughs to produce the kind of outcomes that cancer patients have been waiting for.
Barbara Jacoby is an award winning blogger that has contributed her writings to multiple online publications that have touched readers worldwide.