The Clinical and Reimbursement Landscape of Immuno-Oncology - Episode 4
“For the clinician, there’s a value triad of efficacy, toxicity, and cost,” says Bruce Feinberg, DO, a vice president and chief medical officer of Cardinal Health Specialty Solutions during the fourth part and conclusion of the one-on-one interview series on PD-1 agents. He echoes the thoughts of many payers: Cost becomes the paramount differentiator in the case of multiple oncology drugs that are similar in terms of improving survival, quality of life, and safety.
Dr Feinberg remarks that PBMs make decisions based primarily on cost even if a new drug is administered once daily versus an older regimen that requires a combination of seven pills a day to treat the same condition (eg, hepatitis C). He pointed out that this consideration may apply to the multiple PD-1 agents as well as the biosimilars as they are approved by the Food and Drug Administration (FDA). However, the costs of new specialty medications have become such an issue that some stakeholders are starting to “blur the lines of that value triad, which was fairly consistently upheld for the last two decades.”
If multiple agents are available for a given target, Michael Kolodziej, MD, a national medical director of oncology strategy for Aetna, believes that it would be almost impossible that they would not be covered should the FDA approve it and “the NCCN gives it its blessing.” As a result, he doubts that current discussions about more aggressively managing oncology formularies through will bear fruit.
Dr Kolodziej believes the clinical pathways are the best way today to apply that value triad of efficacy, toxicity, and cost of care. Therefore, it becomes critical to focus on building the pathway (and not deciding whether to cover an individual oncologic medication); pathways are truly an alternative for approaching the formulary management question, comments Dr Kolodziej.