Mini Summit XVII: Case Studies in APM Oncology Payment Innovation

Ray Page, DO PhD

Most Money Goes to Drugs, Hospitals, and Other Services

• Patient Centered care under a Oncology Medical Home principles can reduce hospital costs

• ASCO Choosing Wisely Campaign can control costs from diagnostic imaging and laboratory diagnostics

• In the office, 78% of my medical oncology budget is drugs, hard to budge

Oncologists impact on drug spending

• Oncologists do not control the entry price of new drugs.– Rare exception: Zaltrap vs. Avastin

• Role of Treatment Pathways in Oncology– Management of Drug Utilization and Costs

Pathway Determinants

Efficacy

CostToxicity

Pressure on Drug Pricing?• Can Pathways serve as a mechanism to pressure drug pricing ?• Metastatic colon cancer example

• The CALGB/SWOG 80405 study has shown equivalent efficacy and toxicity between chemotherapy plus bevacizumab and chemotherapy plus cetuximab, yet the cetuximab arm costs $40,000 more for a treatment course

• A properly designed value-based pathway should give clear preference to bevacizumab and only allow cetuximab in circumstances where bevacizumab is contraindicated (uncontrolled hypertension or significant history of arterial thrombotic events, as an example)

• With this explicit and transparent choice based on cost, manufactures should be incentivized to bring the drug costs closer to parity

Schrag D, et al. J Clin Oncol. 2015;33(Suppl). Abstract 6504. http://meetinglibrary.asco.org/content/152903-156. Accessed September 4, 2016.

Via Oncology Pathways: Cetuximaband Panitumumab

Practice Data: UPMC, Indiana University Health

• The colorectal committee determined, based on key studies, that both treatments were equally effective with no significant difference in toxicity

• Panitumumab has a monthly cost advantage of ~14% based on CMS average sales prices

• Intervention: A substitution of panitumumab for cetuximab across all metastatic lines of therapy in the pathway was initiated as of August 2014

• Results: There was a rapid change in the selection behavior between the two drugs

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Cetuximab and Panitumumab

Related Publication: J Clin Oncol 33, 2015 (suppl; abstr e17778)

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Treatment Decisions for Cetuximab and Panitumumab UPMC, IUH

CetuximabPanitumumab

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Journal of Oncology Practice, published on July 8, 2014 as doi:10.1200/JOP.2014.001488

• Eliminating financial drug incentives (ASP + 0%) and narrow episodes of care pathways paradoxically increased use of chemo.

• Substantial total cost reduction ($34MM) resulted from sharing best of practice data and rewarding outcomes, better global management of patients, and primarily keeping patients out of the ER and hospitals.

Bundle Payment Case Study for Treatment of 1st Line Metastatic Adenocarcinoma of the Lung

OCM: Examples of Variation in Benchmark/Episode costs

Breast cancer: on oral part D(each value is 6 month episode) Breast cancer; on systemic treatment (part B)

• Baseline price $4075;• Full dual eligible $ 6218;• Six HCCS $ 9506;• Clinical trial $11,928• Radiation $19,261• Female $41,940• Male $47,103

• Baseline $22,670• Full Dual eligible $27,449• Six HCC $41,961• Clinical trial $ 52,654• Radiation $ 85,033• Surgery $108, 445• Male $121,796

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• Bundled payments transfer of risks from payer to provider• Probability Risk: Out of provider’s direct control

• Random or unpredictable events• Drug pricing• Other doctor’s actions

• Technical Risks: Within provider’s direct control

• Drug/Regimen choices• Treatment Pathways• Ancillary services• Choosing Wisely Campaign• Patient triage Pathways

The Transformation of Oncology Payment

www.asco.org/paymentreform