We Have to Change How We Pay for Cancer Drugs

Jun 15, 2015
Next year, the world is expected to pay more than $100 billion for cancer drugs. But where’s the value?
  • Commercial
  • Cancer

New Pill Bottle

Fighting cancer is hard. And so is paying for the rising costs of drugs that treat it.

We have had many recent great breakthroughs in cancer. Targeted therapies can add months and years of life. Some new therapies harness the body’s own immune system to fight cancer. Science now better complements the tenacity and bravery of cancer patients.

But that tenacity and bravery is more and more being put to the test. To survive cancer means being able to afford the best care possible. As drugs are priced higher and higher, the challenge for cancer patients – and the payers that cover the cost of cancer drugs – to access and pay for drugs only gets larger.

It’s time to rethink how we pay for cancer drugs, and a revolution in how we do that will be driven by an evolution of solutions we already have.

Think about it this way: would you pay the same amount of money for anything in your life that works really well in one way, but not as well in another? Probably not. And it’s hard to even come up with something that fits that description.

But in cancer care, that’s exactly the challenge we face.

A drug like Tarceva® (erlotinib) provides, on average, an additional five months of life for lung cancer patients compared to normal care. The same drug provides, on average, an additional 12 days of life for pancreatic cancer patients. Yet, we pay the same amount for the drug.

We are going to change that.

Solving the Cancer Care Puzzle

Unless current and new therapies are more affordable, patients won’t have the opportunity to take advantage of these treatments.

That is why we’re expanding the dialog about fair drug pricing and value-based reimbursement with thought leaders such as Dr. Peter Bach, Director, Center for Health Policy and Outcomes at Memorial Sloan Kettering, and Dr. Steven Pearson, Founder and President of the Institute for Clinical and Economic Review (ICER). 

With the help of these independent experts, we plan to offer an indication-based formulary for certain medications in 2016. Right now, we're paying top dollar for every indication, including indications where the outcomes for the patient are marginal.

Paying for performance of a therapy should align with the value that therapy delivers to each individual patient. This approach makes therapy more affordable and accessible for all patients.

For an indication-based formulary to work, we have to work with pharmaceutical manufacturers and others in the industry to determine how well drugs work for each individual patient. Scientific advances – such as tumor testing, predictive analytics and pharmacogenomics – will help guide this discussion.

We’re also partnering with many of our clients, who collectively represent tens of millions of patients, to advocate for more affordable drug pricing and expand access for patients, just as we did last year for new hepatitis C therapies.

A Holistic Approach

Integrated care and claims management go a long way in helping payers manage the cost of cancer care. We see two significant opportunities to improve the management of cancer treatment:

First is the management of cancer therapy claims. Currently, almost 77% of cancer drug spend is billed through the medical benefit, where payers have no ability to manage the cost and administration of these expensive therapies. Programs, such as Express Scripts’ Medical Benefit Management (MBM) solution, allow payers to leverage tried-and-true pharmacy practices, including utilization, reimbursement and site-of-care management, to eliminate waste and reduce costs while preserving patient care.

The second opportunity is integrating pharmacy care for patients with cancer, which leads to safer, more effective prescribing and better outcomes. Multiple co-morbidities are common among patients with complex and chronic conditions. Among patients with cancer who had annual drug costs greater than $50,000 in 2014, 56% also had high blood pressure, 35% also had high blood cholesterol, and 28% were also taking an antidepressant.

Leading Co morbidities Among Patients with Cancer

Unmanaged co-morbidities complicate care, jeopardize successful cancer treatment, and can lead to additional, mostly preventable, medical costs and hospitalizations.

A “whole patient,” integrated approach to care – as made available through Express Scripts’ Oncology Therapeutic Resource Center® (TRC) – provides a patients with a primary pharmacist specialized in cancer care who coordinates with the registered dietitian on staff at Accredo, and the patient’s physicians, nurses, other specialist pharmacists and nutritionists involved in the patient’s case. Specialist pharmacists in our Oncology TRC are experts in treatment, risk, possible side effects and drug interactions. This holistic model provides better patient care and can more effectively manage costs.

Cancer patients fight hard enough to survive their illness. Saddling them with skyrocketing drug costs is too much for them to bear. We’re going to solve this problem and make sure everyone gets the value these extraordinary innovations deliver.

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