Immunotherapy and the OCM: Costs and Utilization


Bruce Feinberg, DO: Kavita, if I heard you correctly, you didn’t seem to believe that any of these models were going to necessarily reduce cost. It seems like they may improve quality.

Kavita K. Patel, MD, MS: No, I think they can reduce cost. I just don’t think they’re going to. I think that we’ve had the idea of what… We had thought—we, including me—many people in the early phases of the OCM [Oncology Care Model] thought it was really attacking unnecessary inpatient costs, unnecessary admissions, and unnecessary emergency department care. All that is true; however, I certainly didn’t think that the drug cost would be this overwhelming. Shame on us for that. So I do think that these models can reduce cost. But you have to understand, as a doctor or any clinician does, the underlying root cause of things. You can’t look at the symptoms. I think that what we’ve been doing in payment models is looking at the symptoms.

Bruce Feinberg, DO: If we’re going to reduce cost, and cost is being driven by drugs in this population—so not in all healthcare populations but in this particular population—are we moving toward more companion diagnostic-driven tests or molecular targeting therapies? Even when we talk about I-O [immuno-oncology], PD-L1 [programmed death-ligand 1] won’t be it, and tumor mutation burden won’t be it. We’re going to have to go beyond that to identify who are the most appropriate populations.

Richard D. Carvajal, MD: Appropriate utilization is key, and there are certainly clear examples in which there’s a right or a wrong—HER2 —positive breast cancer, for instance. There’s a clear right or wrong when trastuzumab is appropriate. Unfortunately, we don’t have that for a lot of our therapies. We don’t have data regarding what’s the optimal duration of therapy. “Do we need a year of I-O? Do we need 2 years of I-O? When can we stop?” We’re talking, what, $150,000 a year for some of these PD-1 [programmed cell death protein 1] antibodies. Do we need the year? If drug cost is really what’s driving the rising cost of cancer care, which it is, maybe that’s an area where we do have to focus.

Bruce Feinberg, DO: Ted, you brought that up. Everybody has got to play; everybody has got to be a part of this. But historically, for those trials to be done, PhRMA [Pharmaceutical Research and Manufacturers of America] has got to do those trials. Yet right now they wouldn’t be in there. They’re not in their business’s best interest. So the question is, does it happen or does it not happen?

Ted Okon, MBA: If you look at the landscape in Washington, DC, they are literally after drug prices. I think that the industry has had a little bit of a wake-up call, but I think it has to have even more of a wake-up call in terms of, “This is going to happen.” The days of going after the oncologists to get to the drug companies? Those days are over.

The problem is we do have unsustainable costs. But you also have to look at the mix of cost. Again, I go back to what I said before. If you look at the OCM, Medicare Part B costs have gone up by 26%. If you look at Part D, it’s 280%. So we have an issue there. As you know, 30% to 35% of the pharma pipeline are oral drugs. We have a whole other issue there, and that gets us into a whole other complication. By the way, I’ve said this before, and I’m sure Kavita would be disappointed if I didn’t say it, you’ve got confounding factors like the 340B Drug Discount Program in terms of discounts. You’ve got PBM [pharmacy benefit manager] rebates that complicate this whole model in terms of drug pricing.

Bruce Feinberg, DO: We have 5 minutes left, and you saved that until now.

Ted Okon, MBA: Absolutely.

Bruce Feinberg, DO: I’m not sure if I’m proud of you, or if you managed to work it in again.

Ted Okon, MBA: No, just discipline.

Bruce Feinberg, DO: Rich, it sounds like, as a clinician, the hope and prayer would be that we don’t have kind of a wholesale approach where 1 size fits all and we can’t agree; we’ll just take 10% off the top of everything, and that becomes a solution. Rather, let’s be smart about it. Maybe, let’s do the studies. Maybe we can do 5 or 6 months instead of a year, or 1 year instead of 2. We’ve seen some of it , and sometimes it’s driven by toxicity. In the case of combining CTLA-4 with PD-L1, it was found that the more expensive drug can be given in a lot lower dose and still get the bang for that buck. But it sounds like we’re also going to need the data to say, “We’ve got long-term benefit here, and that means also changing the model from the short term.”

Guys, this was great. I wanted an animated delivery and a lot of cross-talk, and we had it. Thirty-second final thoughts, Susan?

Susan Ash-Lee, MSW, LCSW: Keep the patient first.

Ted Okon, MBA: Thirty seconds, really?

Bruce Feinberg, DO: Just say 340B...

Ted Okon, MBA: 340B and PBM rebates. No, I think that everybody, all the stakeholders here have a stake in this making it successful. I think the OCM has been a success in part, but we’ve got to go to an OCM 2.0, OCM 3.0, and beyond.

Bruce Feinberg, DO: Kavita.

Kavita K. Patel, MD, MS: We need to find a way to engage more hospital and hospital-based facilities. There was meaningful participation, but I think that the beginning of the promise of all of this has to be all in.

Richard D. Carvajal, MD: Yeah. I think that the foundations have been really set, like with the OCM1, and it’s just a question of can we build upon that?

Bruce Feinberg, DO: Thank you all for your contributions to this discussion. On behalf of our panel, we thank you for joining us, and we hope you found this discussion to be useful and informative.

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