Payers Insights Into Future Oncology Management


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Payers Insights Into Future Oncology Management

  1. 1. ON-CONOMYOBRPayers Insights Into Future Oncology ManagementBy Rhonda Greenapple MSPH, President, Reimbursement Intelligence Reimbursement Intelligence, tumor type and staging is being Under the Affordable Care Act,a nationally recognized market used. Accountable Care Organizationsresearch firm, conducted research (ACOs) are considered to be bring-with 50 of the top-ranked man- Quality Initiatives and ing a new model of care for Medi-aged care health plans to better New Care Models care beneficiaries, and are, in effect,understand the current and future Payers recognize NCCN guide- an integrated system that attemptsdynamics in oncology management lines in determining coverage for to eliminate fragmented care forand evaluation of pipeline thera- an oncology treatment with 90% Medicare beneficiaries. ACOs are apies relative to current treatment using Category 1 and Category 2A group of providers and suppliers ofparadigms. This article reviews key recommendations (Figure 1). Payers services (e.g., hospitals, physicians,insights from the survey regarding are also developing quality initia- and others involved in patient care)new care models and payer evalu- tives where they work with oncol- that will work together to coordi-ation of 3 new non-small cell lung ogy practices to gather data and nate care for the Medicare Fee-For-cancer (NSCLC) compounds. outcomes based on accepted guide- Service (FFS) beneficiaries they lines. According to our survey, over serve. They must agree to accept The RIQ 2011 ASCO Special half of the respondents indicated responsibility to serve at leastReport: Payer Reactions to Highly they implemented quality initia- 5,000 Medicare beneficiaries for atAnticipated Innovations and Clin- tives in oncology with either NCCN least 3 years.1ical Data Presentations obtained Quality Measures (35%) or withcritical intelligence from both com- Patrick Cobb, MD, Chairman ASCO Quality Oncology Practicemercial and government managed of Community Oncology Alliance Initiatives (25%).care health plans covering over100MM lives. Medical and Phar-macy Directors were representedequally to ensure both perspectivesin evaluating therapies. Four key tumor types: breast,NSCLC, melanoma, and hemato-logical malignancies were coveredby the respondents—all of whomparticipate in their P&T commit-tee meetings. This article will onlyfocus on the NSCLC section of thereport. Utilizing NCCN Guidelinesand other evidence-based medicineguidelines, payers work towardsmanaging use of less costly thera-pies and ensure that the most effi-cacious treatment for a patient’s Source: Reimbursement iQ: 2011 ASCO Special Report to Latest Clinical Trials26 ONCOLOGY BUSINESS REVIEW • ONCBIZ.COM • JULY 2011
  2. 2. (COA) and the COA Policy Com- ical costs and creation of a viable the cost burden to payers. Unfortu-mittee, and Ted Okon, Execu- risk sharing structure. nately, the 5-year survival rate fortive Director of COA, outlined the all patients with NSCLC was onlychallenges for oncologists in the Lung Cancer Management 15% in the period 1995-2005.3 Withadvent of ACOs, in a recent article In certain cancer types such new treatment options and com-on According to as NSCLC, treatment options are bination therapies, NSCLC thera-Cobb and Okon, “An oncology pro- expanding, but with these clinical pies will continue to be a focus forvider participating in an ACO will gains also come the expansion of oncology management (Table 2).be under enormous pressure to sim-ply control or reduce costs. Support-ers argue that ACOs are differentfrom HMOs, in part because theyare not just about cost-savings—quality measures must be satisfied.However, there are no quality mea-sures for cancer treatment. Fur-thermore, although there is a nodto quality, no one should kid them-selves—ACOs are really all aboutsaving money.”2 Our survey validates the COAleaders’ concerns showing thatincreasing use of lower cost treat-ment alternatives ranks highly asdoes improving overall spendingtracking (Table 1) when the respon-dents were asked to rank in order Source: Reimbursement iQ: 2011 ASCO Special Report to Latest Clinical Trialsof importance primary drivers forpartnering or forming an ACO. Under an ACO structure, oursurvey indicates that health plansanticipate more increased priceconcessions, including more aggres-sive contracting with manufactur-ers (35% of respondents) or moreaggressive pursuit of manufactur-er rebates (10% of respondents).Health plans designing ACOsacknowledge that managing oncol-ogy therapies will have challengesincluding reduction of overall med- Source: Reimbursement iQ: 2011 ASCO Special Report to Latest Clinical Trials JULY 2011 • ONCBIZ.COM • ONCOLOGY BUSINESS REVIEW 27
  3. 3. OBR ON-CONOMY Most new oncology molecules are results showed a median survival of Another product in the pipeline,priced at $5,000 per month or more, 30.6 months with Stimuvax vs 13. 3 [crizotinib; Pfizer, Inc], is an oral,and recently one newly approved months with best supportive care. selective, small molecule inhibi-cancer therapy broke the $100,000 tor for patients with NSCLC who Payers reviewed both products’per year threshold. Several NSCLC express the EML4-ALK gene muta- trial data and Stimuvax effica-clinical studies involve combina- tion. Approximately 3%-5% of cy rated higher than emepepimuttion therapy with biologics as well individuals with NSCLC have this (Figure 2).as second- and third-line therapies. mutation (which represents aboutIn a recent New England Journal of More important, 80% of pay- 6,000 to 10,000 patients in theMedicine article, Thomas Smith, ers rated Stimuvax survival data United States). Most recent dataMD, and Bruce Hillner, MD, con- significant or highly significant. presented at the 2011 ASCO meet-sider whether patients who have However, the majority of payers ing from a nonrandomized, retro-progressive disease after 3 consec- expect these products to be priced spective Phase 1 trial showed thatutive regimens should be switched equal to or higher than Avastin patients who are ALK+ receivingto palliative care specifically where (Table 3). crizotinib as second- or third-linethere are lung and breast cancerguidelines.4 However, payers understanddespite the drug cost that there isstill a need for effective treatmentoptions for NSCLC. In our RIQ2011 ASCO special report, 80%of payers cover the use of Tarceva[erlotinib; Genentech] and Avastin[bevacizumab; Genentech] in non-squamous NSCLC with only 5%placing any restrictions. The report also provided feed-back on 2 new targeted therapies:astruprotimut and empepepimut.Astuprotimut [MAGE-A3 ASCI;GSK] is a targeted immunother-apeutic agent designed to trigger Source: Reimbursement iQ: 2011 ASCO Special Report to Latest Clinical Trialsa specific response against tumorcells expressing MAGE-3 antigen,presenting in 30%-50% of NSCLCpatients. In a Phase 2 trial, therewas a 27% reduction in relative riskof cancer recurrence following sur-gery vs placebo. Emepepimut [Stimuvax; Mer-ck] is a vaccine against cancer cellsexpressing MUC-1 antigen, whichis present in 74%-86% of NSCLCpatients. In a Phase 2b trial withadvanced NSCLC (stage IIIB and IV) Source: Reimbursement iQ: 2011 ASCO Special Report to Latest Clinical Trials28 ONCOLOGY BUSINESS REVIEW • ONCBIZ.COM • JULY 2011
  4. 4. therapy vs ALK+ patients in the ing quality of care while reducing ceivable that lung cancer cancontrol group who had previous- costs. According to the report, pay- become a chronic disease with long-ly received standard of care chemo- ers recognize that diagnostic tests term maintenance therapy. Withtherapy (pemetrexed or docetaxel) will reduce use of ineffective drugs more treatment options and combi-or erlotinib had a 1-year overall and increase appropriate treatment nation therapies, guidelines andsurvival of 70% vs 44%, respective- (Table 4). evidence-based medicine will bely; and 2-year overall survival of critical in containing costs and55% vs12%, respectively. In Conclusion ensuring appropriate care. RI Payers have traditionally not Payers project using crizotinib managed oncology treatment choic-with 23% indicating first-line ther- 1 Summary of Proposed Rule Provisions for es since care is so individualized Accountable Care Organizations Under theapy for EML-ALK gene fusion and many patients face life-threat- Medicare Shared Savings Program, Center forpositive patients, and 42% for sec- ening conditions. However, payers Medicare & Medicaid Services, April 2011.ond-line therapy for EML-4-ALK are looking to new models like qual- 2 Cobb P, Okon T. Just ‘who’ is the oncologistgene fusion positive patients after ity initiatives to allow for better use accountable to in an accountable care organi-failure on chemotherapy alone. zation? September 7, 2010. www.oncologystat. and adherence to guidelines to pre- vent unnecessary or ineffective com/viewpoints/cancer-policy-forum/Just_Who_Diagnostic Value Is_the_Oncologist_Accountable_to_in_an_ care. Many branded lung cancer Manufacturer’s research and Accountable_Care_Organization.html therapies are over $50,000 per yeardevelopment will continue to iden- CDC and Prevention, Cancer Incidence and 3 which is an increasing burden fortify biomarkers and gene selectiv- Mortality Rate, 1995-2005. health plans. However, pipelineity to increase targeted therapies 4 Smith T and Hillner B. Bending the cost curve in therapies for NSCLC are offeringin NSCLC. New diagnostics will be cancer care. N Engl J Med. 2011;364:2060-2065. the hope for breakthrough thera-valued by payers as the tests help pies that can improve the overallensure the right treatment reach- survival for patients. It is not incon-es the right patient thus increas- About the Contributor Reimbursement Intelligence is a nation- ally recognized market research firm specializing in Managed Markets and reimbursement. Our clients include biotech, pharma, and medical device as well as financial analysts and institutional investors. To obtain a copy of the RIQ Special Report, please call 973 805 2300 or email rgreenapple@reimbursementintelligence. com.Source: Reimbursement iQ: 2011 ASCO Special Report to Latest Clinical Trials OBR DAILY NEWS FLASHES ??? JULY 2011 • ONCBIZ.COM • ONCOLOGY BUSINESS REVIEW 29