Value-Based Care Must Be Linked to Improved Clinical Outcomes

February 2016 Vol 9, Special Issue: Payers' Perspectives in Oncology
James T. Kenney, RPh, MBA
Manager
Specialty and Pharmacy Contracts
Harvard Pilgrim Health Care

Society meetings, such as the recent American Society of Hematology (ASH) annual meeting, generate a lot of clinical-related excitement regarding new treatment options, protocols, and pathways for hematologic cancers.

Health plans rely on specialists and presentations from professional meetings to navigate the copious amounts of data being presented over a relatively short period of time. There is also a strong need to balance the clinical advances made with new therapies and the appropriate providers and patients who will have access to them.

The financial concerns of new treatment options are processed in parallel with the clinical review and with the hope for a balance of all things clinical and the limited resources available to pay for these advances in medicine.

Robust Hematologic Drug Pipeline

The hematologic cancer drug pipeline is robust, and many studies presented at the meeting have demonstrated the value of the new treatment options. Furthermore, many new drugs approved in 2015 have significantly advanced the treatment of select hematologic malignancies.

Multiple Myeloma

Patients with multiple myeloma continue to receive the benefit of scientific advances, with new molecules and creative ways to combine them with existing molecules to achieve improvements in overall survival.

The gold standard, bortezomib (Velcade) continues to offer strong clinical value. As discussed by Durie and colleagues at the 2015 ASH meeting, bortezomib is a part of a new standard of care for the treatment of patients with newly diagnosed multiple myeloma. The triplet regimen of bortezomib, lenalidomide (Revlimid), and dexamethasone (Decadron), followed by maintenance therapy with lenalidomide and dexamethasone, achieved 11 months of additional overall survival compared with previous treatment options.

Utilization Management Tools

Furthermore, the approval of 4 new agents for multiple myeloma over the past year, including the 3 drugs that received approval at the end of 2015, presents challenges for health plan formulary committees to evaluate, assess, differentiate, and select the appropriate drugs for formulary coverage. The treatment approaches in the market by clinical hematologists are varied, and they do not always follow a particular pathway or a standard methodology. The opportunity for the development of an approved pathway in multiple myeloma is not clear, because many physicians choose different drug combinations to achieve positive clinical results.

As S. Vincent Rajkumar, MD, pointed out at the meeting, the temptation to use some of the newer agents off-­label or earlier in the treatment regimens is real . This type of concern prompts health plans to create utilization management tools regarding newer agents to limit access to the labeled indications before any expansions in the labels over time.

The potential for an all-oral regimen in multiple myeloma as reviewed by Philippe Moreau, MD, including the first oral proteasome inhibitor ixazomib, shifts the cost burden from the medical benefit to the pharmacy benefit, and enhances the ability to apply utilization management controls to the medications for health plan pharmacy management.

Improving Outcomes at Reasonable Cost

Michael Kolodziej, MD, identifies a number of key areas of opportunity for health plans to achieve treatment success while balancing the cost of care . Quality management principles were introduced to managed care based on the teachings of Edward Deming in the early 1980s, and were incorporated into clinical practice at Harvard Community Health Plan by Don Berwick, MD, as part of a broad attempt to improve the quality of care in a staff model health plan.

In my experience at Harvard Pilgrim Health Care, we were able to achieve significant improvements in quality despite the limited data capabilities.

The discussion of process improvements, decreasing variability, data collection, and value create the setting to achieve improved outcomes at a reasonable cost. The use of the patient-centered medical home model focuses on the importance of care coordination to achieve positive clinical outcomes.

The expansion of specialized care in the medical community shifted the focus away from primary care physicians and toward the use of specialists to treat patients who could not be managed by primary care physicians.

Episode-of-Care Payment System

Joseph Alvarnas, MD, discusses the potential for an episode-of-care payment system that, when coupled with effective care coordination, may lead to improved outcomes and reductions in duplicate services, improvements in efficiency, reduced waste, and, ultimately, lower costs. This process will support the improved management of patients with hematologic cancers and the need to identify, track, and manage the adverse events, drug interactions, and complications of various treatment options.

The patient can get lost in the system because of multiple healthcare providers, service locations, comorbidities, and a lack of strong care coordination. This topic was discussed by Nicola Wallis, MRCPath, FFPM, at ASH 2015; she presented data on chronic myelogenous leukemia (CML) in relation to adverse events and treatment costs associated with them.

The remarkable efficacy of tyrosine kinase inhibitors and their ability to effectively cure patients with CML may have masked concerns regarding adverse events associated with these treatments.

Financial Toxicity

Health plans must evaluate all aspects of each drug to select the ones with the best balance of efficacy, safety, tolerability, and cost. In addition, health plans and providers need to be cognizant of the financial burden that may be placed on patients with cancer.

At ASH 2015, Joanne S. Buzaglo, PhD, discussed financial toxicity, noting it can lead to depression or other poor health outcomes, as well as to poor medication adherence.

The Future of Cancer Care

The future is filled with the promise of new drug approvals, the increased development of targeted therapies, companion diagnostics to match patients to a particular drug, and the potential launches of generic drugs or biosimilars for patients with hematologic cancers.

Health plans must work to balance the current best-in-class treatments with potential generic or biosimilar options that will offer predictable efficacy at a lower out-of-pocket cost for patients.

If we can improve survival, reduce hospital admission rates, and promote cost-effective pathways, we will then achieve improved clinical outcomes while providing significant value to the healthcare system.

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Last modified: March 3, 2016
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