Price is what you pay. Value is what you get. ---Warren Buffet
Nature of the Problem Cancer care costs are growing 15% per year. High prices of brand name drugs are creating a difficult situation for patients and oncologists, who are inadequately prepared for these challenges. Cancer patients are ill-equipped to make difficult trade-offs between high out-of-pocket costs and very expensive treatment with measurable but sometimes modest health benefits. Oncologists are often conflicted about how the cost of care should affect their behavior.
Cost of Cancer Care is Rising → $125 billion in 2010 → $175 billion in 2020
Cumulative % Increase Cancer Medical Cancer Drugs Healthcare US GDP Source: Blue Cross Blue Shield Association Cancer Care Costs Rising Faster than Overall Healthcare
Eight of Top Ten Most Expensive Drugs Covered by Medicare are Cancer Drugs Top Ten Medicare Drugs 2012 Ranibizumab$1,220 Rituximab cancer treatment$876 Infliximab injection$704 Injection,pegfilgrastim6mg$642 Bevacizumab injection$624 Aflibercept1 mg$384 Denosumabinjection$347 Oxaliplatin$309 Pemetrexedinjection$292 Bortezomibinjection$278 Source: Moran Company Analysis of Medicare Physician/Supplier Procedure Summary File, 2012. Includes carrier claims only (physician office and DME). Outpatient Prospective Payment System (OPPS) claims are excluded.. Millions
Projected family health insurance premium costs and average household income Household Income Year Annals of Family Medicine: 2012: 10: 156-162 Patients are Bearing More of the Costs
ASCO Value in Cancer Care Task Force Established in 2007 as the Cost of Care Task Force to define the challenges related to the cost of cancer care and develop strategies to address these challenges in the context of ASCO’s mission Goals: Increase physician education and guidance about cost Increase patient education and assistance regarding cost Promote high-value medical decision-making Assess the value of cancer care
ASCO Efforts to Increase Value in Cancer Care Promoting adherence to evidence-based medicine: ASCO Guidelines Commitment to quality improvement: QOPI Working with payers: Integration of quality measures into reimbursement policy Cultivating a learning healthcare system: CancerLinQ Establishing Clinically Meaningful Outcomes for clinical trials Promoting physician reimbursement reform The Value in Cancer Care Task Force
Patient Resources Goal: To develop communication tools to help patients ask questions about cost, understand the realities of the cost of their treatment and interpret cost-benefit. Managing the Cost of Cancer Care Patient Information Booklet An easy-to-read booklet to help patients start and guide a conversation with their health care team about coping with costs of cancer care. For distribution to patients in the office setting as well as online.
Choosing Wisely Campaign: ASCO “Top 5” Lists for Oncology ASCO has issued two “Top Five” lists of interventions that are frequently practiced but not evidence-based and likely wasteful Examples: Cancer directed therapy in patients with low performance status Imaging in early-stage prostate and breast cancer with low risk of metastasis Use of white cell stimulating factors to prevent febrile neutropenia in patients with < 20% risk
Begins with establishing and achieving clinically meaningful outcomes in clinical trials
Goals To help investigators develop randomized phase III trials that: -are likely to impact clinical care in the era of molecularly targeted therapy; -focus on patient impact, rather than statistical significance To inspire patient advocates to demand more from trials To assist clinical trial sponsors and investigators with setting priorities for pipeline agents
Recommendations for Clinically Meaningful Outcomes Minimum meaningful incremental improvement is an HR of ≤0.8 and median OS improvement from 2.5 to 6 months New regimens that are substantially more toxic than current standards should also produce the greatest increments in OS
Each Stakeholder Has a Role Providers: trying innovative ways to lower costs while improving quality, through mechanisms such as clinical pathways, adherence to evidence-based medicine, QOPI participation Payers: looking to assure highest and best use of limited resources through the development of innovative benefit designs (e.g., value- based insurance) and pay for performance mechanisms Patients: mobilizing to promote access through initiatives such as uniform patient assistance programs, patient navigation, and education of individuals and families about the cost of care and expected outcomes of treatment Manufacturers: finding ways to innovate in the most cost-effective and efficient ways possible; consider new pricing models such as indication-based pricing
ASCO’s Value Initiative In spring 2013, ASCO Board of Directors engaged in a strategic discussion on value around the following statement: –Increasingly, the desired care for oncology patients will be assessed on the VALUE of that care rather than the COST –This is an opportune moment for ASCO to take the lead in defining VALUE and suggesting how VALUE should be integrated into treatment decisions
To achieve a transparent, clinically driven, methodologically sound method for defining and assessing relative value of cancer care options The relationship between clinical benefit, toxicity and cost will be used to assess the value of a new treatment: Clinical benefit (OS, PFS, Palliation, QOL) Toxicity Cost ASCO’s Value Framework
Designed for doctors to use in conversations with their patients to help inform individual decisions. Intended to support consideration of individual patient circumstances and the best evidence available on a particular treatment’s clinical effectiveness, toxicity and cost ASCO will not publish scores, rankings, or other generalizable information about the relative value of specific cancer therapies.
ASCO’s Value Framework Designed to enable comparison of a new treatment with an existing treatment or, if there is no effective therapy, with best supportive care. Assesses value based on three primary parameters: Clinical Benefit, Toxicity, and Cost. Clinical Benefit and Toxicity are combined to form a Net Health Benefit Score, then Cost is integrated to derive an overall Value Assessment for an oncology regimen. Two versions of the framework have been created: one for the non-curative setting and one for use in the curative setting.
ASCO’s Value Framework Pilot tested in 4 clinical scenarios: First line treatment of metastatic NSCLC Castrate-resistant prostate cancer Advanced multiple myeloma Adjuvant treatment of HER2+ breast cancer
Current Status Gathering feedback from stakeholder groups Refining the inputs Preparing a communication plan