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Feasibility of Expanded Emergency Department Screening for Behavioral Health Problems
Mamata Kene, MD, MPH; Christopher Miller Rosales, MS; Sabrina Wood, MS; Adina S. Rauchwerger, MPH; David R. Vinson, MD; and Stacy A. Sterling, DrPH, MSW
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Jonas de Souza, MD, MBA
Risk Adjusting Medicare Advantage Star Ratings for Socioeconomic Status
Margaret E. O’Kane, MHA, President, National Committee for Quality Assurance
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Melony E. Sorbero, PhD, MS, MPH; Susan M. Paddock, PhD; and Cheryl L. Damberg, PhD
Cost Variation and Savings Opportunities in the Oncology Care Model
James Baumgardner, PhD; Ahva Shahabi, PhD; Christopher Zacker, RPh, PhD; and Darius Lakdawalla, PhD
Patient Attribution: Why the Method Matters
Rozalina G. McCoy, MD, MS; Kari S. Bunkers, MD; Priya Ramar, MPH; Sarah K. Meier, PhD; Lorelle L. Benetti, BA; Robert E. Nesse, MD; and James M. Naessens, ScD, MPH
Patient Experience During a Large Primary Care Practice Transformation Initiative
Kaylyn E. Swankoski, MA; Deborah N. Peikes, PhD, MPA; Nikkilyn Morrison, MPPA; John J. Holland, BS; Nancy Duda, PhD; Nancy A. Clusen, MS; Timothy J. Day, MSPH; and Randall S. Brown, PhD
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The Value of Novel Immuno-Oncology Treatments
John A. Romley, PhD; Andrew Delgado, PharmD; Jinjoo Shim, MS; and Katharine Batt, MD
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David H. Howard, PhD; Brad Herring, PhD; John Graves, PhD; and Erin Trish, PhD
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The Value of Novel Immuno-Oncology Treatments

John A. Romley, PhD; Andrew Delgado, PharmD; Jinjoo Shim, MS; and Katharine Batt, MD
This study assesses the value of novel immuno-oncology treatments to society.
DISCUSSION

This study investigated the social value of the survival gains from novel I-O treatments, specifically, ipilimumab for advanced unresectable melanoma and nivolumab for advanced previously treated squamous NSCLC.
We estimate that ipilimumab substantially improves real-world discounted life expectancy over an existing standard of care, and nivolumab for NSCLC would also generate substantial gains if durable survival comparable with ipilimumab for melanoma resulted. An economic model for valuing discrete changes in longevity indicates that the improvement in life expectancy is worth $465,000 to a patient with melanoma and $381,000 to a patient with NSCLC, based on an intermediate value for a key model input (income).

These findings are consistent with a value of a statistical life-year of approximately $230,000. Reviews of the literature on the value of occupational and nonoccupational safety point to a value of a statistical life-year of anywhere from $150,000 to $360,000, and out-of-pocket health spending by patients with cancer reveals a willingness to pay for survival of a comparable magnitude.33-35

Aggregating value per case across the patients treated over a 5-year window, we estimate that ipilimumab treatment of melanoma generates $1.9 billion in value for society, whereas nivolumab treatment of NSCLC would generate $1.7 billion in value for patients with durable survival. We estimate that profits to the pharmaceutical manufacturer represent 28% of the total social value of ipilimumab treatment in melanoma and 12% of the value from nivolumab in NSCLC.

Limitations

Our analysis has a number of limitations. Our approach to estimating long-term survival likely understated survival gains from I-O treatment because it assumed that patients were cured at the end of follow-up under an existing standard of care, as well as I-O treatment. In addition, recent evidence on 5-year survival with nivolumab for NSCLC is more favorable than our own estimates applying findings from an earlier analysis of pooled studies.15,36 These studies were based on dosing according to weight. The most recent label specifies flat dosing, at a level below what would be typical under the original label9; on the other hand, our estimate of the cost of nivolumab treatment used the median number of infusions from the pooled studies, which understates the actual average with durable survival and maintenance therapy per the current label. Due to uncertainty about real-world utilization of these treatments, as well as ongoing developments in cancer treatment, we considered a relatively short time horizon (5 years of new cases) and explored the sensitivity of our results to alternative scenarios for utilization. Another limitation is that this study has not addressed quality of life. Existing evidence is limited but nevertheless suggests that I-O treatment can maintain baseline quality of life and thus contribute to value.37

CONCLUSIONS

Despite these limitations, this study has important implications for patients, payers, and policy makers. The National Academy of Medicine and numerous stakeholders have emphasized the need for better value in healthcare.38,39 Certainly, I-O treatment is not low-cost; we estimated that ipilimumab treatment of a typical case of advanced unresectable melanoma cost nearly $147,000 for drug acquisition. However, the question of value is always: Where do the benefits stand in relation to the costs?40 In healthcare, the benefits are the health outcomes achieved for patients—in our case, substantial survival gains. As has been found in the context of traditional chemotherapy, as well as chronic medication, spending on the I-O treatments studied here represents a modest fraction of the economic value of the survival gains produced by the treatments.12,13 Our findings suggest that novel I-O treatments have strong potential to yield not only favorable prognoses but also good value.

Author Affiliations: Price School of Public Policy and School of Pharmacy, University of Southern California (JAR), Los Angeles, CA; University of Texas Health Science Center (AD), San Antonio, TX; Precision Health Economics, LLC (JS), Santa Monica, CA; Wake Forest University (KB), Winston-Salem, NC.

Source of Funding: This study was funded by Bristol-Myers Squibb.

Author Disclosures: Dr Romley consults for Precision Health Economics, funded by Bristol-Myers Squibb and others, and Precision Health Economics compensated him for this manuscript. Dr Delgado was previously employed by Precision Health Economics. Dr Batt reports consultancies or paid advisory boards for Bayer, Bristol-Myers Squibb, Novartis, Novo Nordisk, Pfizer, Precision Health Economics, and Shire, as well as meeting/conference attendance for the European Association for Haemophilia and Allied Disorders, American Society of Hematology, and International Society on Thrombosis and Haemostasis. Dr Shim reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JAR, AD, JS, KB); acquisition of data (JAR); analysis and interpretation of data (JAR, AD, JS, KB); drafting of the manuscript (JAR, KB); critical revision of the manuscript for important intellectual content (JAR, AD, KB); statistical analysis (JAR, JS); provision of patients or study materials (JAR); obtaining funding (JAR); administrative, technical, or logistic support (JAR); and supervision (JAR, KB).

Address Correspondence to: John A. Romley, PhD, USC Schaeffer Center, Verna & Peter Dauterive Hall (VPD), 635 Downey Way, Los Angeles, CA 90089-3333. Email: romley@healthpolicy.usc.edu.
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