Evidence-Based Oncology

Immunotherapy in Cancer Care: Understanding the Impact of Shifting Treatment Paradigms in the Managed Care Setting | Page 5

Published Online: March 20, 2014
Part Two
Dr Kolodziej: The truth of the matter is that we actually don’t really know how cancer patients are going to be taken off within that construct. Because the benefits design is a very basic benefits design. It’s better than nothing, but I think the question is, so how do you take care of cancer in that universe? I assure you they would pay premiums in the health information exchanges for several years for how much it costs for 1 cycle, 1 treatment of Provenge. So I think its unclear how cancer care is going to happen in that world. Now, that’s the immediate change. The long-term change of course is going from fee-for-service, paying for transactions to paying for value. When I was in practice, I thought, “There’s no way that ACO is going to happen,” and you know what, now I think they’re going to happen.

Dr Salgo pointed out that he did not agree with this. Since a part of the drug cost includes research and development, if the drug manufacturing cost alone is covered, then it might just freeze the system.

Dr Kolodziej: We talked about the possibility that up to 30% might be waste. I’ve always thought of that as the pool of money to pay for innovation. That’s my own perspective, not Aetna’s, but I’ve always thought that’s a lot of money…So the challenge is “Who’s going to be the ACOs?” There are integrated delivery systems like the Mayo Clinic and Geisinger. There are numerous hospitals that aspire to transform themselves to be ACOs. There are a lot of reasons why it’s hospital systems, but let’s just accept the fact that hospital systems are the predominant player in this area. They’ve got to really change the way they’re thinking about care. Keeping beds full is no longer your primary driving force…If we can execute that change, that’s where the money comes from.

Dr Salgo then specifically asked Dr George and Dr Weber how they thought the ACA would particularly impact immunotherapy. In their opinion, would it help or hurt the implementation of immunotherapy and research and development?

Dr George: This is a dynamic area. This is a phased healthcare reform and, as pointed out by Dr Kolodziej and Dr Weber, the first phase is greater access to patient care. Now, these are expensive therapies and to what extent the basic plan, or the Medicaid plan, covers an expensive therapy remains to be seen. But I’m encouraged because patients who are most likely to benefit most from immunotherapy are going to be more likely to have some insurance to allow us to treat them. The societal benefit is that we treat the right patients with the right drugs, and avoid waste.

So the patients that have some coverage now they can get that, and we’ll be able to increase that enrichment strategy.

Dr Salgo: Is the way to carve out your 30% waste that you could put it going forward, is that going to be at the cost of small practices versus large practices, large practices that achieve economies of scale?

Dr Weber: I’m not in private practice, so it’s not something I’ve thought extensively about, but I don’t see that point. I think that if you’re practicing value medicine, you should be able to survive in a

small group or a large group.

Dr Salgo asked whether the days in which the doctor could treat a patient, unmindful of the associated cost, were numbered.

Dr Kolodziej: I think so, and we need to get comfortable with the idea that…As a healthcare consumer, I appreciate that we’re getting to a record-and-verify point in healthcare. Doctors who do a good job are thinking of ways to continue to do a good job going forward, while those who don’t want to be told what to do, well, you know what? Sorry.

Dr Weber: Data talks. To paraphrase an old radio commercial from New York when I was growing up, data talks and nobody walks.

Dr George: Just so we don’t lose sight. Cost is really not the equation. We’re talking about value, which is quality over cost. What I don’t want to see happen (are limits) on practitioners who do a good job and actually keep a patient alive longer. By selecting the right therapy for the right patient, they actually get a really good treatment response that’s going to cost more inevitably. And so, to some extent, you’re penalized for doing a quality job. I think we have to recognize in the end that it’s not the lowest cost that wins here.

Dr Salgo: Although, if you listen to the debate in Congress, that’s often what you hear.

Dr George: That’s what I worry about.

Dr Kolodziej then asked the other members on the panel their definition of quality.

Dr Salgo: It’s amorphous, isn’t it?

Dr Weber: Quality-adjusted years of life prolonged would be a reasonable parameter.

Dr George: Life prolonged. The problem is on an individual basis; how do you know you prolong that life? On an individual basis, we can use prognostic models and nomograms. It’s an imperfect science.

Dr Salgo pointed out that the focus is always on the length and quality of life, disregarding aspects like physician interaction with the family to discuss outcomes and options.

Dr Kolodziej: So the answer is, if you look at some of the proposals for quality metrics, and some of them are outcomes like quality adjusted life years and some of them are process measures. Patient satisfaction is typically included in that. I think that the time has long passed where we need to be more transparent about our outcomes. We need to be more transparent about what people think of us. We all remember that cardiothoracic surgery was such a big deal, and reporting the outcomes of cardiothoracic surgery was such a big deal. And now it’s held up as the model for transparency, and fairness, and shared decision-making, consumerism. But people would not be comfortable with that in oncology.

Dr Salgo then raised a chicken-or-egg argument. Of the 12 cancer drugs approved by the FDA in 2012, 11 cost more than $100,000 a year, either coincidentally or maybe these are just expensive technologies to develop. The technology cannot be developed unless someone pays for it, and unless you got the $100,000 for a therapy that does seem to work, we wouldn’t have it. How would this argument fit in the model?

Dr Weber: Well, the companies will only develop the drugs if they can make money selling them. But if the companies are convinced that, at the end of the day, they’ll be able to sell the drug for a profit, whatever that may be, they will continue to develop new and innovative drugs that will benefit patients.

PDF is available on the last page.