John Fox, MD, MHA: In second-line therapies, there are certainly several options available: immunotherapy alone or anti-VEGF (anti—vascular endothelial growth factor) therapy with chemotherapy. We know that the results are better than with chemotherapy alone. The costs of those regimens are different. As a health plan, though, our obligation is to cover evidence-based care. And as long as the evidence supports the use of those therapies, the cost-effectiveness isn’t really an issue for us. I think it becomes more of an issue for providers who are taking risk—for example, under the Oncology Care Model— in assessing whether or not the incremental differences between one regimen and another are clinically relevant.
It’s fascinating. There was a study published by AJMC®, done by Avalere Health, that showed that perhaps 10% of patients don’t fill their initial prescription for an oral oncolytic. There are probably many reasons for that. Cost may certainly be one of those reasons. In our own experience, as a health plan, we found that 17% of patients never filled beyond the first script, which caused us to provide 15-day supplies rather than 30-day supplies for drugs that could cost anywhere between $8000 and $15,000 a month.
From our vantage point, making sure that there are multiple options for patients and providers is important. Providers and patients may agree that an intravenous therapy is most conducive to their long-term adherence and may produce a better outcome for patients. But at the same time, there are others where this is an issue—especially those who may live a distance for whom traveling to get IV chemotherapy or immunotherapy may be a challenge. So, again, I think it’s really a decision for the provider and the patient to make about how to optimize their outcome and how to optimize adherence, not only to oral but IV regimens, to produce a regimen that’s most consistent with the patient’s preference.