Monday, March 25, 2013

Cancer and New Therapeutics

There is an explosion of new cancer therapeutics. About ten years ago we saw imatinib for CML and now we have quite a few for metastatic melanoma, once a terminal disease for certain. In the Melanoma case we see some 20% may survive for extended periods of time. However the average life extension may be only 6 months at a cost that may exceed $100K. In addition there may need be several of these therapeutics used at one time.

A former Administration Health Care adviser has written on this of late:

Many cancer patients, after getting a diagnosis of a terrifying disease, pursue any potentially promising therapy, regardless of the price. But the main cost driver is the fee-for-service payment system. The more doctors do for patients, the more reimbursement they receive. Surgeons earn more for every procedure. Oncologists typically make more money if they use newly approved drugs and the latest radiation treatments than if they use cheaper, older alternatives that work just as well. (This is because they get paid back the cost of the drug, in addition to an extra 6 percent of that cost — the more expensive the drug, the higher the compensation.)

 His point is the 6% on the $100K charge. That is $6K per patient per six months. Take melanoma. The incidence is about 75K per year. Of that some 12K to 20K it the drug profile. At say $100K per person and assuming all persons, 20K, we would have in any one year $2B in costs and $120M paid to Oncologists. Is that too much? I guess it depends if you are in the 20% or the 80%.

He suggests changes:

First, over the next few years, the payment system needs to move away from fee-for-service toward a system of bundled payments, in which doctors are paid one fee for all the treatments involved in caring for a cancer patient.

Point well taken. But the problem is the way we compensate people based upon past assumptions.

Second, insurers have to give physicians information about where they are spending money. 

I would suggest the patient also be informed. Patients all too often assume that the costs of the medication is low. They have no idea what the costs are. Moreover the basis for the costs should also be known. One must remember that the drug companies have gone through multi-Phase trials of hundreds of patients each at tens of thousands per patients just to the management of the Trial. Recall that the CROs, the Clinical Research Organizations, generate almost $30B in annual revenue just managing the Trials to comply with the FDA. That is not money in the pockets of the Pharmas.

Third, any change in payment methods must be accompanied by rigorous quality monitoring to ensure that there is neither under- nor over-utilization of care.

 Quality, now just what do we mean by that? This is what drove the character nuts in the Zen and the Art of Motorcycle Maintenance. Really, is it nothing more than what is in the eye of the beholder.

Fourth, we need more “high touch” oncology practices. In these practices, nurses manage common symptoms before they escalate to the point that they require visits to the emergency room..

 Part of this is that the Oncologists are dealing with a mass amounts of new and different genetically targeted drugs which address pathways that they may have never been exposed to in Medical School. One melanoma drug leads to a new skin cancer, an unexpected effect.

Fifth, we need better incentives for research. Many expensive tests and treatments are introduced without evidence that they improve survival or reduce side effects, and with poor information about which patients should receive them.
Here I would disagree. The Trials are somewhat extensive but when you apply something used over 600 people to 20,000 you get a whole new set of issues. A drug may have to be withdrawn.

One key question is who should receive the new therapeutics? How do we manage them? Cancer is terrifying to the patient. But we now have an environment where people can find out about these new medications and demand them. Physicians are then pressed to use them, albeit with little significant survival benefit, on average. Yet that 20% who do survive contain valuable information for the next step.

Thus do we view use of the new therapeutics as the cost of continuing research or the cost of providing care?