Melanoma: From Impossible to Treat to Poster Child for Targeted Therapies | Page 4
Published Online: October 23, 2013
Produced by Nicole Beagin
Weber: I think this is something that is at the top of everybody’s consciousness in the medical field. There are a number of things that will come into effect over the next few years, in that the NCI, the FDA, just about every professional group is going to emphasize the idea of trying to have biomarkers to select the right patients. You can’t just treat 100 patients and benefit 8 of them. It is not going to happen in the future, and the FDA has made it very clear how important they think biomarkers are. The classic was the B-RAF mutation test that was approved when they approved dabrafenib, so the 2 variables will be selecting the patients more appropriately, and determining what the value will be. I predict that you are not going to get the (Oncologic Drugs Advisory Committee) and the FDA to approve drugs or push forward unless there is clear, significant value; a 5-week prolongation of survival is not going to cut it in the next 10 to 20 years, not when the drug costs $120,000 just for the wholesale price. As Dr Malin just pointed out, you increase the price because you have to add the margin of profit for the hospital, you have to add the nursing costs, the infusion cost, the doctor cost, etc, so those 2 driving forces will help, and the final thing is, there is only so much money in the world and certainly there is only so much money in this country.
At the current rate, I suspect if you graph the price of current drugs over the last 20 years, you would see at least a linear increase with a doubling every 5 years and eventually what is it going to be, $300,000, $400,000, $500,000, or $600,000 to treat someone? That is just not practical. There will be pushback from citizens, there will be pushback from every walk of American life. People study this, and Dr Ribas probably knows these data and can correct me if I get it wrong, but Tom Smith, who used to be at the Medical College of Virginia and is now at Hopkins, studies what Americans think would be a proper amount of money to spend per year of life...the so-called marginal value of a drug, and it is not $500,000, it is not $20,000, it is somewhere between $50,000 and $180,000, and that is kind of where ipilimumab is and vemurafenib is. You are adding, and looking at the dabrafenib, trametinib price together, and if you add it together and multiply that by the profit margin and then you add that it is a monthly charge over a year or 2 years, it is $200,000 a year. I just think people won’t accept it, and I think the companies are going to have to cut the price. I’m not an economist, but I find it hard to believe that for them to stay in business they need to charge $200,000 a year for dabrafenib and trametinib.
Fendrick: Dr Weber, we don’t have anyone representing the manufacturers’ side on the line, but you are falling into my own area of expertise and all of the numbers you say are, of course, right on, except it is not talking about who is actually paying, the employer or the government through organizations like WellPoint that are paying these dollars.
Weber: You and I are paying. It is our tax dollars that are going for this.
Fendrick: I wanted to ask a question, an easy one, and then comment on some areas where The American Journal of Managed Care has taken the lead. Dr Ribas and Dr Weber, I would like you to comment on whether you actually feel there is cost-related nonadherence and lack of access right now, and I just want to throw out very quickly the concept that the other co-editor of The American Journal of Managed Care, Mike Chernew, and I developed over 10 years ago called value-based insurance design, and you should at least find some solace to know that one of the slowest areas of healthcare cost growth in the United States is pharmaceuticals overall, largely because of the emergence of generics in the small molecule market, and everyone is focusing, of course, on you guys in the specialty pharma area where almost every American who has coverage, and especially in pharma, pays an equal amount of coinsurance on every drug. That being a drug that cures cancer like the ones you are talking about, as well as ones that hardly work at all, or even best case scenario, prolong life by just a few months, so we have proposed with great support from ASCO, NCCN, and COA and everyone else, an idea to extend value-based insurance design to especially pharma, where coinsurance would go much lower for the drugs that work as well as you say, particularly in the case of metastatic melanoma, and cost sharing would go up when you use agencies that are off label or for rescue therapy, and this is being discussed by multiple stakeholders that are used in other areas of medicine now, but now just being explored in, especially, pharma. Imagine that a combination is discovered that works all the time, regardless of the manufacturer’s price, the cost to the patient would be lower than for a combination of agents that you would never, ever use but see being used out there by people behind the curve. With that editorial comment, what do you see happening now regarding cost-related lack of access or nonadherence, if at all?
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