Evolving Strategies for Cost-Effective Cancer Management

October 2012, Vol 3, No 7 - AVBCC Annual Conference


Houston, TX—A wealth of new agents and abundant clinical trial data supporting their use have led to multiple “acceptable” evidence-based options for treating tumors. This can make the “real-life” care of patients with cancer confusing with regard to disease outcomes and in the assessment of value propositions related to treatment, ac­cording to Atheer A. Kaddis, PharmD, Senior Vice President of Managed Markets, Diplomat Specialty Pharm­acy, Flint, MI.

At the Second Annual Association for Value-Based Cancer Care Con­ference, Dr Kaddis described the evolving strategies being applied to pay for cancer care in an ever-challenging landscape.

“We are having this conversation to try to determine the value of our available therapies and to learn how to manage them for the best outcomes at the lowest cost,” he said.

As payers grapple with finding value, Dr Kaddis says, they have some important unanswered questions, such as:

  • How is the cost for new oncology agents justified?
  • What is the most cost-effective option for a given tumor and treatment setting?
  • Can significant restrictions be placed on oncology medications?
  • What is the role of nondrug therapy?
  • Should end-of-life discussions and interventions occur earlier in pa­tients with serious illness?
  • What can be done to prepare for the high-cost therapies currently in the pipeline?

Best Practice Strategies
“The use of best practice strategies is growing, and offers opportunities for value,” Dr Kaddis said. These strategies, in order of importance to payers, include drug therapy management (high-touch patient care management), channel management (medical to pharmacy benefits), utilization management (prior authorization and step therapy), formulary management (use of preferred drugs), and drug cost management (average wholesale price discount improvement).

The increase in the availability of oral anticancer agents elevates the importance of formulary management and channel management in oncology, he said. For example, in renal-cell carcinoma, there are now 7 approved agents, lending this tumor type to formulary management, and as oral drugs replace their intravenous counterparts, there will be opportunities to shift drugs to specialty dispensing and away from the buy-and-bill model.

In addition, utilization management continues to be a powerful approach for payers, primarily employing prior authorization to ensure that prescribed agents are being appropriately used.

Adherence to these best practice strategies will yield savings opportunities. The impending entrance of biosimilars to the market raises the following questions and concerns in terms of drug utilization.

Questions and Concerns about Biosimilars

  • Will biosimilars cost less than brand-name reference products? If so, how much less?
  • Will biosimilars be accepted as alternatives to brand-name reference products by physicians, payers, and patients?
  • How will biosimilars be marketed by manufacturers and which manufacturers will develop these products?
  • How will biosimilars be identified?
  • What type of patent protection will biosimilars have?
  • Will there be manufacturing issues surrounding biosimilars?
  • Will biosimilars be substituted within a therapeutic class (ie, step therapy) or will they be considered alternatives only to the specific reference product?
  • Can we take information already available on European biosimilars to speed entry into the US market?
  • What will happen to the brand-name drug market in the United States?
  • Will the Centers for Medicare & Medicaid Services include biosimilars in their calculations to determine average sales price?
  • Will biosimilars be considered brand-name or generic drugs, or will we have to develop a new category?

Partial Fill Strategies
The use of partial fills has been expanding for oral oncolytics, and the experience of Diplomat Specialty Pharmacy demonstrates the savings opportunities. The focus of the program has been on the oral agents erlotinib (Tarceva), sunitinib (Sutent), and sorafenib (Nexavar). The program is now expanding to include 10 drugs.

“Some of our payers are discussing putting partial fill limits (a 15-day supply) on all oral oncolytics used as maintenance,” Dr Kaddis said. “According to our data, 25% of patients discontinued therapy after the first partial fill (first month), and 50% of these patients died. This led us to believe that these therapies are being tried as a last-ditch effort. This was a shock to us, and has spurred discussions about limiting all oral oncolytics to partial fills when given as maintenance.”

Nearly 30% of Medicare expenditures are made in the last year of life. Instead of paying for cancer care when it is futile, Dr Kaddis suggests that payers support programs such as Cancer Coach, which focuses on palliative care for patients with a new cancer diagnosis, as well as the dying patient, and on quality of life versus quantity of service provided. The Cancer Coach program facilitates enrollment into hospices, with patient and family support, and coordinates interventions with the case management department.

Payers should partner with physicians to develop these programs, or at least encourage physicians to initiate productive end-of-life discussions with patients, Dr Kaddis suggests.