New Century Health recently convened health plan executives, industry experts and oncologists from across the nation to discuss the confluence of forces shaping oncology care in 2021 and beyond—and what can be done now to prepare. The panel of guest speakers included:
- Carolyn R. (Bo) Aldigé, Founder and Chief Executive Officer, Prevent Cancer Foundation
- Dr. Roy Beveridge, Medical Oncologist; Senior Strategic Advisor, Avalere Health
- Susan Dentzer, Senior Policy Fellow, Robert J. Margolis Center for Health Policy, Duke University
- Dr. Vinay Prasad, Hematologist-Oncologist; Author of Malignant: How Bad Policy and Bad Evidence Harm People with Cancer
Key insights from the half-day gathering about the primary forces shaping the future of oncology care include:
The State of Oncology
New Century Health CEO Dan McCarthy summed up the field as “a specialty in chaos for so many reasons.” Factors contributing to the state of affairs include:
- Overwhelming growth of new knowledge. An oncologist would need to devote roughly 40 hours a week to stay current on clinical literature in their field. It’s a nearly impossible task to keep up with the avalanche of new drugs and indications, and the evidence surrounding drug efficacy, to know what treatment regimens will provide the best outcomes.
- Out-of-control costs. Of 12 cancer drugs that received FDA approval in 2019, 11 cost more than $100,000 per treatment. Such price tags are fueling the growth in cancer spending, expected to reach $240 billion by 2023.1
- Financial toxicity. Increasingly, the costs are borne by the patient. Two years after a diagnosis, 42% of patients have exhausted their life savings. One of every five cancer patients spends at least $20,000 a year in out-of-pocket expenses for their care.2
- Pandemic impacts. Delayed screenings due to COVID-19 could result in a wave of new cancer diagnoses that are more advanced, and therefore more deadly and expensive to treat. At the same time, payers will be under increasing premium pressure as the government and employers seek to recover from the toll of the pandemic. If nothing is done, cancer care will continue to consume a greater share of the health care dollars that could otherwise go to other needs, such as diabetes or behavioral health.
A Lopsided Value Equation for Cancer Drugs
Despite the hype and hope attached to new cancer therapies, many fall far short of what we would expect given their high price tags. Guest speaker Dr. Vinay Prasad, a hematologist-oncologist at University of California-San Francisco and author of Malignant: How Bad Policy and Bad Evidence Harm People with Cancer, highlighted some of the problems in oncology drug value.
- Poor outcomes relative to cost. Some oncology drugs have been true gamechangers. Gleevec, for example, has nearly restored full life expectancy in patients with chronic myelogenous leukemia. But such examples are rare. A study of 71 consecutive FDA approvals for solid tumor drugs found that they provided a median improvement of just 2.1 months of additional survival.3
- Flawed clinical trial design. Clinical trials often overstate the (often modest) benefit that patients will receive in the real world. Overall, oncology clinical trial participants are younger and healthier than the general cancer population, and they tend to have better outcomes. In real-world patients, the benefits shown in trials sometimes vanish. Additionally, about two-thirds of FDA approvals for new oncology drugs are based on surrogate endpoints, such as tumor shrinkage, rather than the most important measure—how long they extend life.
- Broad panel gene sequencing. As of 2018, roughly 9% of patients with advanced cancer were eligible to receive a drug targeted at a genomic mutation.4 These can be potent (and very expensive) treatments for some patients. However, matching to a targeted treatment does not guarantee better outcomes. The same drug that successfully treats BRAF mutations in melanoma produces no benefit for multiple myeloma with the same mutation. Such “mirages” are common, and Prasad estimates that the true percentage of patients who would benefit from one of these targeted therapies is less than 2%.
Lasting Impact of COVID-19
Cancer costs were already skyrocketing prior to 2020, and the pandemic threatens to accelerate that growth.
- Drop-offs in screenings and visits. Cancer screenings plummeted in the spring of 2020, and while they have started to recover, the latest COVID-19 surge may roll back progress. Unsurprisingly, patients cite fear of health care settings as their reasons not to get cancer screenings, according to research by the Prevent Cancer Foundation. Additionally, while some oncology practices say they were able to keep patients with cancer on their treatment schedules through the pandemic, several studies found that, in April, visits for new patients were down 70% while visits for returning patients were down 65%.
- Stage migration. When patients return for screenings and their cancers are eventually diagnosed, they will likely be caught at later stages, when the prognosis is worse, treatment options are fewer, and the costs to treat are much higher. Potential waves of late-diagnosed cancers could drive up costs just as the health system is attempting to recover from the pandemic.
- Silver linings? The pandemic has forced the field to make changes that they may want to keep for the long run. Using telehealth to deliver palliative care, which patients and providers like, is one such area, although payers have yet to commit to keeping such programs after the pandemic.
The Need for High-Value Pathways
Throughout the forum, speakers and participants discussed clinical oncology pathways as an indispensable component of the march to value. Pathways should prioritize those regimens with the greatest efficacy and least toxicity, with lower cost serving as a tiebreaker between roughly equivalent options. Themes emerged around the following topics:
- Not “cookbook medicine.” Efforts towards evidence-based medicine and greater standardization of clinical practice often run into criticism. But guest speaker Dr. Roy Beveridge, medical oncologist and senior strategic advisor at Avalere Health, says that following high-quality, value-based pathways leads to better medicine. Pathways bring together evidence-based medicine with precision approaches that tailor regimens to subpopulations of patients. It’s a superior practice to the shoot-from-the-hip approach that is all too common in the field.
- Real-world evidence. Given the limitations of clinical trials data, there’s enthusiasm for using real-world evidence (RWE) to enhance the quality of pathways, as well as tailor them more precisely to different patient subgroups. After a drug receives approval from the FDA, RWE can inform the field on whether the survival benefits shown in clinical trials are similar in the broader cancer population. RWE could also help assess whether improvements in surrogate measures, such as progression-free survival, translate to similar benefits for overall survival.
Driving Provider Behavior Change
The best pathways in the world won’t make a difference if providers and practices don’t use them. The discussion highlighted three key approaches for health plans to encourage high levels of adoption.
- Demonstrate clinical expertise. Oncologists need to believe that pathways prioritize patient outcomes before cost, and that they are based on science. Engaging directly with oncologists about specific prescribing decisions, as NCH does, can help explain the evidence behind the preferred regimens.
- Financial alignment. Traditional fee-for-service medicine stands in the way of high-value pathways. For example, a substantial portion of oncology practice revenues—about 30%—come from the markups they apply to drugs they dispense. In this buy-and-bill setup, practices suffer financially when they seek out equally efficacious, but less expensive agents. Alternative payment models, such as paying providers a set fee per case regardless of drugs dispensed, can help compensate for lower drug margins. Speakers and participants described a variety of approaches to encourage use of pathways as a way to ensure clinical effectiveness.
- Feedback of performance data. Appealing to oncologists’ competitive nature, not to mention their commitment to their patients, can be just as powerful as financial incentives. None wants to be considered below average, so when they see valid, reliable data showing that they lag their peers in use of evidence-based care, they are more likely to change prescribing behaviors. In many cases, providers have never seen their own performance metrics and don’t know how much variability exists within their practices or profession.
If you’re interested in attending future New Century Health oncology forums, reach out to Kathryn Honeycutt at firstname.lastname@example.org.
1 IQVIA: Global Oncology Trends 2019; Cancer Insurance
2 Adrienne M. Gilligan, PhD; Alberts D; Roe D; Skrepnek G. 2018. Death or Debt? National Estimates of Financial Toxicity in Persons with Newly-Diagnosed Cancer. The American Journal of Medicine, vol. 131, no. 10, pp. 1187-1199.E5.
3 Fojo T, Mailankody S, Lo A. Unintended consequences of expensive cancer therapeutics—the pursuit of marginal indications and a me-too mentality that stifles innovation and creativity: the John Conley Lecture. JAMA Otolaryngol Head Neck Surg 2014;140:1225-36.
4 Marquart J, Chen EY, Prasad V: Estimation of the percentage of US patients with cancer who benefit from genome-driven oncology. JAMA Oncol 4:1093-1098, 2018.