Implications of the New Provider-Driven Value-Assessment Tools in Oncology

Larry Blandford, PharmD; Dan Renick, RPh

July 2015, Vol 6, No 6 - VBCC Perspectives


Given the number of oncology agents introduced over the past 5 years, and the corresponding rise in costs, it is little surprise that multiple organizations are reacting with methods to assess value. Although payers have historically been the default for assessing value to determine formulary coverage, the most recent entrants of the American Society of Clinical Oncology (ASCO), with its value framework, and Memorial Sloan Kettering Cancer Center (MSKCC), with its DrugAbacus, into this arena represent providers of oncology care. Historically pegged as solely focused on clinical evidence and seeking effective therapy at all costs, the focus by providers on the value of cancer care is increasing.

Two forces in particular underpin these actions. First, healthcare delivery system reform is shifting population management and financial risk to providers. At the same time, patient cost-sharing for cancer drugs continues to escalate as a result of the growth of high-deductible health plans and the proliferation of oral oncolytics, where cost-sharing in the pharmacy benefit can be even higher than infused drugs that are traditionally covered in the medical benefit.

For innovators of cancer treatments, the shifting role of providers is of critical importance to the way they have historically mar­keted their drugs: drive prescriber ­demand and secure reasonable access through benefit coverage. This does not mean that payers are any less influential. Based on our internal research, payers expect contracting for access to grow in certain tumor types, with more than 80% of payers responding to our research noting breast cancer treatments in particular.

The positive attributes of the development of these value-­assessment tools is that they provide a framework to support treatment decisions between physicians and patients, who have growing financial interests to match their clinical intentions. That these most recent value-assessment tools were developed by entities led by physicians rather than by payers provides another level of credibility for their intended use. However, these tools are limited to a handful of variables that may not link ­directly to the primary interest of each stakeholder. For example, payers typically hold overall survival rates as the most relevant value metric, whereas patients have been shown to value the level of hope in long-term survival.

The primary takeaway from the recent release of these provider-driven value-assessment tools in cancer care from ASCO and MSKCC is that more stakeholders are evolving their evaluation of oncology treatments to align to the health policy priority of value-based healthcare. The implications for providers are that incentives that are tied to guidelines will likely diminish their traditional autonomy over cancer care, along with addressing the sometimes perverse incentives to prescribe the most expensive medications.

As a result, physicians will need to be armed with new tools to understand and manage financial risk, informing new approaches to medical training and risk management solutions. Each of these developments will advance the movement toward well-designed, value-based care in oncology, as all parties search for ways to improve outcomes. This concept was recently featured in the Health Affairs blog in an article entitled “It’s Time for Value-Based Payment in Oncology” that explores the topic more deeply.1

Reference

  1. Goldman D, Lakdawalla D, Newcomer L. It’s time for value-based payment in oncology. Health Affairs blog. April 28, 2015. http://healthaffairs.org/blog/2015/04/28/its-time-for-value-based-payment-in-oncology/. Accessed July 2, 2015.