Washington, DC—Risk arrangements with physicians and transferring the costs of care onto patients are expected to increase in 2017, as payers attempt to manage high-cost disease states, such as cancer care, said Marie A. Hollowell, Senior Manager, Syndicated Research, Zitter Health Insights, at the Sixth Annual Conference of the Association for Value-Based Cancer Care.
Payers are considering several cost-management measures, and many payers have indicated an openness to the expansion of contracting for first-line as well as second- and third-line therapy, although the huge wave will not hit for another few years, said Ms Hollowell.
In 2015, 13% of payers indicated that they were contracting for first-line therapies for multiple myeloma, according to the Zitter Health Insights Managed Care Oncology Index. And 67% of payers expect to do so by the end of 2017 (Figure 1).
However, 57% of payers said that they are unlikely to create separate market baskets based on the drug’s mechanism of action for non–small-cell lung cancer.
“Even though manufacturers take huge measures to distinguish themselves by what it is they’re targeting in the body, these distinctions are not being made by payers, at least not currently,” Ms Hollowell said.
Leveraging biosimilars is also on the payer wish list, but research with commercial payers indicates that biosimilars may have a large impact in only a few subcategories of cancer, such as non-Hodgkin lymphoma, she said.
“This is different from what we see in other specialty categories, like immunology, where it’s anticipated to have a huge impact. That’s simply because, with all of these new therapies coming out, the value of creating a biosimilar for an older oncolytic drug isn’t terribly beneficial for more than about a year or 2,” said Ms Hollowell.
Other cost-saving avenues for payers include closed formularies, application of value frameworks and clinical treatment pathways, unique risk arrangements with physicians (ie, price-for-performance contracting), and more cost transferred to patients.
Closed formularies are not in the immediate future, but payers suggest that the healthcare delivery system will use them more often to control the cost of expensive monotherapies and combination therapies in oncology, with Medicare leading the way.
Price-for-performance contracting links the price of a drug to its outcomes. Payers engaging in price-for-performance and risk-based contracts indicate that measuring outcomes is difficult and time-consuming; however, it can be done with the proper infrastructure, which is often found with large, national plans.
The top 3 subcategories that are anticipated for price-for-performance contracting are multiple myeloma, breast cancer, and colorectal cancer.
Although some payers have been successful in implementing clinical pathways, others are reluctant to implement them because of a lack of competition across oncology practices, as well as legal and contractual hurdles, Ms Hollowell said. Approximately 76% of commercial payers who indicated that they were using clinical pathways revealed that these were developed internally rather than relying on external resources (Figure 2).
Major factors cited as influencing the development of internal pathways are the National Comprehensive Cancer Network (NCCN) guidelines, medical committee review, NCCN Evidence Blocks, current contracts with manufacturers, and drug compendia.
Many payers do not enforce the use of clinical pathways as strongly as perceived “because they’re looking for a level of physician buy-in that they don’t feel they’re going to get,” said Ms Hollowell. “Quite frankly, they don’t want to alienate their network by trying to enforce these pathways in an official capacity,” she added.
Value frameworks may present a platform for payers to manage combination therapies more aggressively than at present, while taking into account survival end points and similar metrics. The American Society of Clinical Oncology Value Framework assesses the value of cancer therapies by using a scoring system based on a scale of 0 to 30, with metrics to measure value, including clinical benefit and drug toxicity. Bonus points are also awarded for improvements in cancer-related symptoms.
The NCCN Evidence Blocks assign each therapy option a score in 5 categories, including efficacy, safety, quality of evidence, consistency of evidence, and affordability. Only 21% of payers anticipate incentivizing physicians for using the NCCN Evidence Blocks in their prescribing decisions, Ms Hollowell said.
Commercial payers consider value frameworks a great initial stepping stone to informed decision-making, but value frameworks are not a centerpiece of decision-making. “Payers are looking for something much more comprehensive. They’re looking for something that perhaps manufacturers can provide them. Ideally, they would love a third party to provide that kind of information,” Ms Hollowell said.
Payers desire more complex algorithms than the NCCN Evidence Blocks.
“They’re looking for a series where you can actually go in and compare multiple drugs at any given time across multiple metrics,” she said.