mini summit xvii: case studies in apm oncology payment
TRANSCRIPT
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Mini Summit XVII: Case Studies in APM Oncology Payment Innovation
Ray Page, DO PhD
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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
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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
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Pathway Determinants
Efficacy
CostToxicity
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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.
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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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1.P
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.
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Bundle Payment Case Study for Treatment of 1st Line Metastatic Adenocarcinoma of the Lung
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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
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The Transformation of Oncology Payment
www.asco.org/paymentreform
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