A Lonely Voice Asking Tough Questions on Cancer Cost-Effectiveness
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access to a database maintained by the National Cancer Institute, which keeps track of treatments patients are given, and their outcomes. But that’s only a piece of the puzzle he’s looking for. To get a more contextual picture of cost-effectiveness, he wants to form partnerships with health providers that have a lot of other data on patients in their electronic medical record systems. And he wants to bring the insurers to the table, too, because they are the ones with another piece of the puzzle: claims records. If you can stitch those things together to get a more holistic view of cost and effectiveness, it could become a valuable resource to educate the public in the Seattle area, and it might even be scalable to the rest of the country, Ramsey says.
“We hope to be able to educate people about value in healthcare,” Ramsey says.
Ramsey has already dug up some disturbing findings about how much money is spent, and how little value is gained. One study showed that among patients who have insurance, almost 40 percent suffered from “severe financial strain” which was defined as re-mortgaging one’s home to afford medication, borrowing money from friends, or using up their life’s savings. Another study found that Genentech’s hit antibody drug, bevacizumab (Avastin), had almost a zero percent chance of being cost-effective for lung cancer patients (actually, it was a 0.2 percent probability). That hasn’t stopped the growth of cancer drug spending. Now that some cancer drugs can routinely cost $10,000 a month, and insurers are looking to shift more of the cost burden onto individuals, individuals are going to feel pressure to pay up at one of the most stressful and scary moments in their lives. The bills can now add up incredibly fast.
“It’s easy to spend $250,000 treating a cancer patient in a short period of time,” Ramsey says.
Even as the costs keep going up, and cancer patients ought to be doing better, deep disparities remain in how cancer patients get treated depending on where they live, how much money they make, and which institution or doctor they originally see. Just by shining a light onto those cost-effectiveness disparities—which Atul Gawande did with McAllen, TX in an influential New Yorker article a couple years ago—could make a huge difference, Ramsey says.
I wouldn’t go so far as to say we need a draconian system to discourage drug developers from creating new products. Drug prices are rising fast, but there are a lot of other factors contributing to increased healthcare spending. Drug companies can, and should, be able to recoup the investments they make in the form of high drug prices. But if you’re going to charge a high price for a drug, I think a company needs to have a much stronger value proposition than “Hey, we shrank tumors in half for 20 percent of patients. Now hand over your $100,000.” It needs to be more like, “Hey, my drug has an 80 percent chance of helping people with this genetic profile, and those people can expect to live an extra year, with high quality of life.” Now you’re starting to really talk about $100,000 of value.
Sadly, drug companies tend to be more interested in satisfying the short-term profit desires of their investors than they are in truly delivering cost-effective care to patients. Ramsey told me about research he’s done into Amgen’s pegfilgrastim (Neulasta), a white-blood cell booster that helps patients fight off infections when their immune systems are weakened by cancer chemotherapy. Ramsey and colleagues wanted to know if this drug—an effective product that generated $4 billion in revenue last year for Amgen—was being utilized among patient groups most likely to benefit. He found it was underutilized among patients at the highest risk of a dangerous complication known as febrile neutropenia, and it may be overused by patients who had a low risk. (Amgen, when asked if it changed marketing practices in response to the findings, said in an emailed statement that the drug should be used in accordance with its FDA approved prescribing information. “Our marketing efforts reflect our emphasis on first and every cycle treatment as the best way to reduce the risk of febrile neutropenia in appropriate patients.”)
Given that we’re in the thick of corporate earnings season, you can expect to hear a lot of companies reporting on all the usual measurements of success to their investors about sales, profits, earnings-per-share. You will not hear companies talking about proper utilization of their products. But pharma companies would be smart to get more engaged with the health economics crowd, which looks at different barometers of success, like how many quality years of life patients can get from certain healthcare interventions.
It’s easy to find drug companies, hospitals, and health insurers that say they are all about improving patient outcomes. Being against cost-effectiveness sounds bad, like being against Mom and apple pie. Nobody wants to say they are against delivering better patient outcomes. But actions, as always, speak louder than words. It’s time for these various profit-minded players to prove their commitment to cost-effective patient outcomes, by getting more serious about asking these kinds of questions. If we don’t, we’ll just end up paying more and more in taxes and insurance premiums for cancer care, with no real idea of whether it’s worth the money.