How can cancer care decisions be based on value? Two champions are starting to add science to this controversial discussion, which will eventually help all stakeholders make more informed decisions. Peter B. Bach, MD, MAPP, of Memorial Sloan Kettering Cancer Center has published several articles regarding the high cost of new drugs, claiming that the manufacturers have total price control, which has led to irrational pricing behaviors. Dr Bach promotes a more rational, “value-based” approach, where the outcome determines the price.1
The other “champion,” the American Society of Clinical Oncology (ASCO), has developed an impressive model designed to help patients and physicians understand and calculate the net health benefit (NHB) of each potential therapy.2 It factors the clinical benefit and toxicity with cost, and arrives at the NHB score for that drug. Metrics are based on evidence from clinical trials and often reported data, such as clinical outcomes, toxicity, and patient acuity related to advanced disease. ASCO’s eventual goal is developing user-friendly software that can be used in a variety of modes and is integrated into the electronic health record system. The evolving model will include the patient’s preferences, making it truly patient-centric.
These efforts are excellent first steps to understanding and supporting decision-making in the complicated world of healthcare finances that is emerging as a result of increasing costs, new technology, and changing regulations. I applaud these efforts and take this opportunity to suggest some future steps required to fully resolve the healthcare problems facing us today.
- ASCO is correct in starting with a model based on key components that are currently measurable, while acknowledging that new data will eventually be needed. Each category of stakeholders (eg, payers) must collectively determine and agree on the outcomes they wish to measure, then collaborate with other stakeholders (eg, providers and informatics) to collect and publish the results of those new metrics
- ASCO is correct in starting with 4 primary stakeholders—the patient, the manufacturer, the provider, and the payer; however, other critical stakeholders must eventually contribute. Informatics vendors must develop systems capable of collecting required data in discrete fields. Guidelines and protocol vendors must build more complex models that include patient acuity, toxicity, and cost. Employers must help determine the “social cost” related to work productivity and lost wages. Regulators must involve all stakeholders in their considerations
- Computer applications developed to support patient-centric decisions must help patients understand their own responsibility and accountability in their care. Once established, these tools should prompt and measure patient compliance and self-monitoring, leading to financial and other incentives
- Manufacturers must become more responsible in developing tools to better predict clinical response and patient-specific problems. True sharing of risk should be financially rewarded based on better outcomes, replacing many of the current market forces that determine profit margins
- Dr Bach and ASCO both address drug cost,1,2 which is complicated by currently reported numbers that include average wholesale price, average sales price, average manufacturer price, and wholesale acquisition cost. What comprises the “true” drug cost—the actual amount paid for the drug? Or should drug administration, cost to monitor, cost to treat toxicities, and indirect overhead costs also be considered? What is the true cost of developing and manufacturing a drug, and why is there so much variation? It is crucial for a single method to be decided and used for making clinical decisions.
- Loftus P. How much should cancer drugs cost? Memorial Sloan Kettering doctors create pricing calculator that weighs factors such as side effects, extra years of life. Wall Street Journal. June 18, 2015.
- Schnipper LE, Davidson NE, Wollins DS, et al. American Society of Clinical Oncology statement: a conceptual framework to assess the value of cancer treatment options. J Clin Oncol. 2015 Jun 22. Epub ahead of print. Updated 2015 July 13.