Bringing drug costs down a ‘peg’ or two
Click Here to Manage Email Alerts
At our center, metrics obtained through our participation in CMS’s Oncology Care Model have allowed us to improve patient experience scores, reduce ED utilization and hospital admission, and impact several other measures of quality care.
These interventions are important and have high impact for our patients. However, from a cost perspective, they are relatively minor in the context of overall costs of care per Oncology Care Model (OCM) episode. The predominant cost driver for these episodes is the drug spend.
OCM skeptics — previously including me — point to this observation as evidence of the futility of the alternative payment model concept. They argue that because the major driver of cost is the drugs and those costs are beyond our control, our ability to truly impact costs of care is very limited.
It’s true that oncology drug pricing is a complex, opaque process.
Multiple stakeholders have influence over drug pricing — including, for example, manufacturers, pharmacy benefit managers, pharmacies and health plans. As individual health care providers, there’s not much we can do to directly impact pricing.
The continued increase in the price of oncology drugs has been discussed extensively, but without an obvious change in trajectory — prices of new drug continue to rise and the burden of financial toxicity for patients is worsening, especially with additional financial hardships as a result of the COVID-19 pandemic.
Interventions to reduce drug costs
Despite this context of rising drug prices, emerging data demonstrate that there are interventions that can reduce the costs of drugs in a meaningful way while maintaining and, in many cases, improving the quality of care and patient experience.
These data have come from various sources, including OCM participants, and provide insights into small changes that can have significant implications for costs of care. Although some of these data relate to antineoplastic drugs, others relate to drugs used for supportive care, particularly hematopoietic growth factors.
For example, pegfilgrastim (Neulasta, Amgen) is widely used as primary and secondary prophylaxis against neutropenia and neutropenic fever for patients receiving chemotherapy. Although evidence-based guidelines on its use from organizations such as ASCO and National Comprehensive Cancer Network have existed for many years, pegfilgrastim frequently is used outside those guidelines.
In fact, pegfilgrastim accounts for more than 5% of the total cost of cancer care in the OCM — a remarkable figure for a supportive drug. Reducing the cost of this drug could significantly impact the cost to the health care system and potentially reduce a patient’s out-of-pocket costs.
The possibility of safely avoiding the use of pegfilgrastim has been evaluated in a single-arm study at Dana-Farber Cancer Institute that included 125 women with breast cancer receiving dose-dense doxorubicin, cyclophosphamide and paclitaxel.
After completion of dose-dense doxorubicin and cyclophosphamide, Vas-Luis and colleagues gave paclitaxel at 2 weeks but omitted pegfilgrastim following paclitaxel unless the patient experienced neutropenic fever, infection or a treatment delay in a previous cycle.
Only 4.3% of paclitaxel cycles required pegfilgrastim support and 90% of women completed paclitaxel within 7 weeks. The authors estimated that this resulted in a potential cost savings of between $500,000 and $1.7 million per 100 patients treated, with reductions in out-of-pocket costs for women, especially for those without commercial insurance, compared with the previously accepted standard of care.
Use of biosimilars
Another strategy reported recently is the use of biosimilar pegfilgrastim.
In a study presented during the ASCO20 Virtual Scientific Program, Webster and colleagues examined the average CMS reimbursement for pegfilgrastim among Medicare OCM participants before and after the introduction of biosimilar pegfilgrastim in 2018.
They found that prior to availability of biosimilars, the reimbursement for pegfilgrastim increased at a rate of $292 per year. Since biosimilar introduction, the reimbursement rate has fallen by $93 per year.
The average total reimbursement per dose had risen steadily until 2018 and has remained stable since the availability of biosimilars. The authors estimated that the introduction of biosimilars will result in savings of more than $150 million this year.
What’s particularly interesting is that the estimated savings are not due to a major switch from the original pegfilgrastim to biosimilar — more than 90% of patients were still receiving the original product, but the biosimilar effect has exerted some downward pressure on price. The message is clear, however — if only a 10% conversion to a biosimilar can produce savings of this magnitude, there is substantial opportunity to save more.
This was evaluated in another study, also presented at ASCO, which explored the financial impact of substitution of pegfilgrastim with biosimilar pegfilgrastim-cbqv (Udenyca, Coherus Biosciences).
Over six cycles of therapy, McBride and colleagues estimated a cost savings of about $1,300. Based on a panel of 20,000 patients with cancer, the researchers estimated that the cost savings for six cycles of therapy would allow for an additional 6,921 doses of pegfilgrastim biosimilar to be purchased with the savings if there was 100% conversion from the original to the biosimilar.
‘Relatively simple changes’
These are remarkable figures and, of course, estimates.
I am certainly in no position to comment on the modeling used in these studies and, meaning no disrespect to the authors, it’s also important to point out that these studies were funded by a biosimilar manufacturer. At least one previous systematic review has reported an association between industry funding and a favorable result for the sponsor in cost-effectiveness analyses.
It’s important to be circumspect about these results, but they certainly point toward a relatively simple intervention that could have a big cost impact.
Even bigger cost impacts will require thoughtful changes to our use of antineoplastic drugs, the source of most of our drug spend.
A recent report has shown the effect of clinical pathway use and its impact on drug costs in the context of the OCM. In this study, Hertler and colleagues at a single practice demonstrated that as the degree of care pathway adherence increased during OCM participation, the drug spend — initially 13.5% higher than the average for OCM — fell to just 0.1% higher. This represents a reduction in costs of about $250,000 per physician.
In the spirit of transparency, I should point out that the actual drug costs went up slightly over the period of the study, but this was related to external price issues.
As individual oncologists, our direct influence on drug pricing is limited and we need to rely on our professional bodies and the Legislature to bring the current situation under control.
That said, these studies show that we can make relatively simple changes that produce meaningful savings to our health care systems and, more importantly, to our patients.
These small incremental savings add up to a lot of money in the bigger picture.
References:
Al-Badriyeh D, et al. BMJ Open. 2017;doi:10.1136/bmjopen-2016-012648.
Hertler A, et al. J Oncol Pract. 2020;doi:10.1200/JOP.19.00753.
McBride A, et al. Abstract e19372. Presented at: ASCO20 Virtual Scientific Program; May 29-31, 2020.
Webster J, et al. Abstract e19362. Presented at: ASCO20 Virtual Scientific Program; May 29-31, 2020.
Vas-Luis I, et al. J Clin Oncol. 2020;doi:10.1200/JCO.19.02484.
For more information:
John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is associate director for clinical affairs at Harold C. Simmons Comprehensive Cancer Center at UT Southwestern Medical Center. He can be reached at john.sweetenham@utsouthwestern.edu.
Join the Conversation:
Share your thoughts on this editorial at healio.com/authors/jsweetenham.
Collapse
Read more about
Click Here to Manage Email Alerts