Value-based Considerations of CDK4/6 Inhibitors in the Treatment of Metastatic Breast Cancer - Episode 5
A discussion among the panelists on the provider’s responsibility to the cost burden of therapy.
Bruce Feinberg, DO: So Bill, this is always so tough for doctors, and the answer, at least per the Oncology Care Model [OCM], has been to make the treating physician more responsible in some way for the global cost of care. Although you’re a doctor at a major academic institution, you may not be personally feeling that impact as you would in a private practice that’s in the OCM model. You’re however aware of this movement toward physicians somehow being responsible for the total cost of care. I’m curious, in a value-based care world, if you might be willing to opine for a minute or so on that.
William J. Gradishar, MD: You’re correct, we are somewhat shielded from that in the kind of institution we work in, a big university. That said, we’re still cognizant of the choices we’re making. As someone who oversees the women’s health cancer program, if somebody is trying to create some treatment regimen that nobody has heard of, that comes to me for approval. That becomes more common, as you know, as we get into this era of “precision medicine,” where if you get a molecular test, you make up something because there’s oftentimes no data to support it, and you’re asking for approval for something that is clearly not one of the indications for that drug. So that’s not an uncommon phenomenon from that perspective.
As a community, we’re starting to more broadly look at how we judge the efficacy of therapy, not only in terms of clinical end points, but cost. For instance, the NCCN [National Comprehensive Cancer Network] evidence blocks are an effort to take into account not only clinical benefit and toxicity, but also cost is part of that. We haven’t really legislated that one thing should be over the other based on cost; that’s not the mandate of the NCCN. I think it is something that we’re inevitably going to have to confront because the costs, which we’ve been saying for years and years and years, are out of hand. As new drugs come on board, and many are coming and that’s a great thing, it’s just inevitable that the costs are going to outstrip our resources. I think as a community, at some point, we’re going to have to confront this head on.
Bruce Feinberg, DO: Joyce, how close do you think we are to having to have that confrontation? In the current environment of the pandemic, it just feels to me that it has escalated that conversation, from something that you feel like it’s just going to be hyped in every election cycle, and then it’s going to go back to a back burner. It just feels that now, in the current environment, something is going to happen sooner than later.
Joyce A. O’Shaughnessy, MD: What do you mean, Bruce? Are you talking about a single payer system, or?
Bruce Feinberg, DO: Whatever that may be, but it feels like the current model is not working. What I’m hearing, what I heard from Kelli is that it’s literally month to month. What I heard from Steve is it’s complicated and there’s no perfect solution and payers are struggling with it as much as patients are struggling with it. Bill has weighed in that it’s an imperfect design and that efforts like NCCN try to increase the awareness. They’ve moved to preferred regimens and not just levels of evidence, so you don’t just have 12 level-1 evidence regimens to choose from, but 2 or 3 stand out. I’m curious if you think that we’re going to be moving sooner than later, whether it is universal coverage, a single payer. Are you more of the pessimist that it’s going to be more of the same and we’re going to continue to struggle with this, or do you think that there’s something more definitive that’s going to happen in the shorter term?
Joyce A. O’Shaughnessy, MD: I agree that the current situation is not likely to persist indefinitely. I’ll tell you, when I have to do 2 to 3 peer-to-peers to get something approved for my patient. As we all know, the process is very, very challenging. I often, of course, will ask to speak to an oncologist as a peer-to-peer, but sometimes it’s not available. People are trying the best at our practice to navigate me on to the right telephone call and everything, but I’m trying to get a brain CT for a patient of mine. You know, it’s not even that expensive in the scheme of the things that are expensive in medicine. So far, I have had 2 peer-to-peers and I haven’t talked to the right person yet. It’s so complicated, everybody is trying their best but everybody has their own rules to go by. I think it’s just become complex to a level that’s unsustainable in terms of just us accessing things.
I’ll tell you where I put my hope, and that is our big EMRs that allow us to really understand the cost of caring for populations. I’m hopeful, and this is where I think the OCM is moving. Let’s say that 80% of care is just absolutely on guidelines. It’s kind of very predictable, we know the median time on treatment, we know the cost. We’ve got 80%, fine, you can budget for that. You can look at all the imaging, I think we over image—we can cut back on imaging, etc. So, I think 80% is OK. Then there’s always that 20% that you know you have to budget for that, and as Steve said, there’s off-label use, and as Bill said, there are emerging examples. For example, using 1 of the PARP inhibitors that is very expensive for not just germline BRCA1 or 2, but germline PALB2, you know, emerging evidence at ASCO [American Society of Clinical Oncology] this year that that might be helpful, but that’s certainly not on NCCN, for example. There has to be some consideration and accommodation for the 20%, but I think you can build those budgets. As Bill said, if somebody is way off the reservation and making something up that has no basis whatsoever, well that’s not reasonable. On the other hand, we have patients where precision medicine will help them, etc., and some of these are very costly. But I’m optimistic that we can build these budgets as a team.