Bruce A. Feinberg, DO: It seems to me that both value and cost are very different things to each of the stakeholders. We have been a little bit focused, right now, on that patient perspective, but each of you have a perspective to share. And Mike, I want to start with you as a former practicing oncologist. How do you think the provider sees cost and value? I don’t think it’s going to be the same for each stakeholder.
Michael Kolodziej, MD: So for the oncologist, when they’re trying to weigh through the value decision, let’s just talk about cost, that’s relatively easy. I think the only thing to actually think about, by and large, is whether or not the patient can afford it. Whether or not the patient can accept this therapy given the economic burden it’ll place on them. I don’t think oncologists think about anything else when they make or have a shared decision-making discussion. I definitely don’t think they think about “ASP + 6” [average sales price plus 6%].
I will go formally on record as saying that oncologists never think about what the ASP is so that they can increase the plus 6 part of it. In therapeutics, that just doesn’t happen, right?
Outcomes—outcomes are harder for oncologists. There is not an oncologist who doesn’t like telling the patient that the tumor is smaller. That’s response rate. That’s not a very good outcome, right? It’s a weak outcome. Progression-free survival—oncologists like not having to change therapy. Changes in therapy or transitions in therapy are uncomfortable for the doctor and the patient.
Bruce A. Feinberg, DO: Right, they’re a big stress factor.
Michael Kolodziej, MD: They are very stressful. Survival—I have a chance to cure you. Of course they think about how likely it is they’re going to cure the patient. They would love to be able to offer that to more patients.
Those are the outcomes that they think most about when making a treatment decision. They also think about the toxicities they wish to avoid. Everybody uses the example of the piano player and paclitaxel. Fine, that’s okay. That’s old hat, but there’s a lot of other ones. Hair loss is a big one. Fatigue is another big one. Does fatigue mean that I won’t be running the next marathon, or does it mean I won’t be able to get out of bed in the morning? Fatigue is a big one. So, I think toxicity.
Bruce A. Feinberg, DO: I would add neuropathy because it’s so insidious. You know, “You may be grade 2, but you have the rest of your life...”
Michael Kolodziej, MD: It always gets worse after you stop the drug, right? It never just stops like that. So, I think that when an oncologist is making a decision about outcome, they do think about response rates, progression-free survival, and survival. They think about therapeutic alternatives, especially from the perspective of toxicity. I think that is the value equation for an oncologist.
Bruce A. Feinberg, DO: Half of the oncologists are now working for an integrated delivery network, which is very different than it was 5 or 10 years ago. So, is it all oncologists, or is that the perspective of the private practice oncologist? Or if it is oncologists, how is the decision making different when that oncologist is a staff physician in a bigger organization that might have a different value and cost perspective?
Ted Okon, MBA: I can tell you that if you look at the United Study, which basically looked at taking away the so-called “incentive” and had a number of community oncology practices, the write-up on that appeared in one of the peer-reviewed journals said, “paradoxically,” when the so-called incentive was removed, drug spending went up 179%.
I think there’s a lot of reasons. We don’t have to talk about them now, but that’s kind of interesting. The other interesting thing is when you look at the government’s own watchdog that looks specifically at hospitals that are 340B hospitals that don’t have plus 6, but they have plus 100 on to the cost of the drug, the Government Accountability Office said, “They prescribe more or more expensive drugs.”
Michael Kolodziej, MD: I think it’s fair to say that, and I’ve looked at the claims trail for physicians who practice on both sides. I looked at the hospitalization rates, and the emergency room visit rates, and the length of stay. They’re not that different. If you’re an oncologist, you’re an oncologist.
Now, there may be institutional preferences. I’ll tell you what I mean by that. I remember very well when I was in practice that if you had a patient that was being taken care of in the hospital under a DRG [diagnosis-related group], the likelihood you could give that patient pegfilgrastim was zero. There’s no way the hospital pharmacy is going to eat that charge within the DRG. They won’t let you do it. They may have formulary differences, but the truth of the matter is that I don’t think the pattern of care is all that different unless it’s influenced at the formulary level.
Ted Okon, MBA: I agree with you for the most part, Mike. But there are now some heavy institutional pressures. What I mean is there are administrators who realize that, “Oh, my gosh, this drug has a huge margin associated with it.”
Michael Kolodziej, MD: No, I agree.
Ted Okon, MBA: And not that they’re pushing, but they are trying to push in that direction. I’ve got some great examples of where the administrator has come along, especially from newly-acquired practices that don’t yet have, for example, 340B pharmacy, and have said to give “this part of the drug” over here. “This” meaning the brand drug. And basically, the patient has to drive 10 miles to go to the hospital that is 340B. Then, step back and you can give the generics because they’re not worried about the margins being as high. So, I absolutely think beyond just the normal formulary and the P&T committee at the institution level, there are some differences.
But I totally agree with Mike. You don’t have oncologists routinely sitting around with a calculator in their head saying, “Oh, the ASP is this plus 6, so therefore, I should prescribe this.” They’re looking at it from the patient’s perspective, because here’s what’s happening. They’re sitting there with an increasing army of individuals who are trying to figure out how they can get copay assistance. They call the National Patient Advocate Foundation and say, “How can we get this drug?” “How can we get some help on this drug?”
That’s happening more and more. It’s really focused more on the patient because if the patient can’t pay, the patient doesn’t take the drug, and the physician, therefore, doesn’t realize any of the outcomes measures that Mike was talking about.