Insurance Exec to Oncologists: Take Financial Toxicity Vow

Nick Mulcahy

March 27, 2018

ORLANDO, Florida — The runaway costs of cancer care in the United States could be markedly reduced if practicing oncologists learned the cost of the treatments they prescribe, said a long-time insurance executive here at the National Comprehensive Cancer Network (NCCN) 23rd Annual Conference.

To do that, oncologists need to take a vow, said Lee Newcomer, MD, MHA, who recently retired as senior vice president, oncology and genetics, UnitedHealthcare.

"Pick up a pen and commit…and [write]: 'I will make financial toxicity as important as medical toxicity and outcomes,'" he told the audience during the meeting's keynote session, titled "Transforming Cancer Care in America." The proposal received some modest applause.

"It has to become part of our daily life," Newcomer told the audience.  Knowing the financial impact of treatment should be a "passion" on par with taking care of patients, he added.

"When that happens, costs will come down, I guarantee it," Newcomer declared.

When that happens, costs will come down, I guarantee it. Dr Lee Newcomer

Drugs account for 45% to 50% of the total cost of cancer care in the United States, and opportunities abound for cost reductions, he said. Newcomer cited a 2017 analysis of bone-modifying agents for patients with metastatic breast cancer (J Clin Oncol. 2017;35:3978-3986). The bisphosphonate zoledronic acid (taken once a quarter) was roughly equivalent in efficacy to the monoclonal antibody denosumab ( taken once a month), according to the authors.

The per-year costs were $200 for zoledronic acid and $25,900 for denosumab.

This price differential has recently been highlighted by multiple myeloma expert Vincent Rajkumar, MD, a professor of medicine and a hematologist/oncologist at the Mayo Clinic, Rochester, Minnesota. He noted in a Twitter thread that the difference in price also leads to a difference in reimbursement, as "we have a system that rewards oncologists and their chemotherapy offices with more $ for giving more expensive chemo."

Physicians can't know the cost of every drug — but having a "mindset" about financial toxicity is a starting point for reform, Newcomer said. Certain drugs are commonly used, and those are the low-hanging fruit for gaining cost expertise, he suggested

An oncologist in the meeting audience questioned the practicality of the proposal.

It is "very difficult" to estimate out-of-pocket expenses for the typical Blue Cross/Blue Shield insured patient, said Samuel Silver, MD, professor of internal medicine, University of Michigan Comprehensive Cancer Center, Ann Arbor.

That's because such insurance "represents maybe 1 of out of 200 different contracts" with "multiple different copays and deductibles," he pointed out.

An out-of-pocket expense is not known until the patient goes to a pharmacy and has the prescription filled, Silver said during the question-and-answer period after Newcomer's talk.

"It's something that is good to know, it's just difficult to know," said Silver.

Medscape Medical News asked Newcomer about Silver's observation. "Many payers have an app where the physician right in the office can check to see what the copayment is," he responded.

Physicians can also learn about drug costs "by anecdote, just the way we learned clinical medicine," added Newcomer. "Start learning something once a month, once a week…and then use that information," he emphasized.

At times, there is not much a physician can do to protect patients from the high cost of drugs, suggested Newcomer.

He reviewed ALK inhibitors for lung cancer, a "superb" class of drugs that met a "very real need" and generate a "huge improvement" in overall survival, he said.

When the first ALK inhibitor, crizotinib (Xalkori, Pfizer), was approved, it cost about $12,000 per month. There are now six such drugs, and four are recommended by the NCCN. Newcomer looked up the retail prices for a month's supply of the four at his local grocery store pharmacy: Crizotinib now costs $15,900; ceritinib (Zykadia, Novartis), $15,300; alectinib (Alecensa, Roche), $14,300; and brigatinib (Alunbrig, Takeda), $20,000. "Four drugs…all remarkably priced the same," he said.

In general, there is no cost competition in the arena of cancer drugs, Newcomer stated. That is a problem rooted in how the United States approves and pays for drugs.

"We have to get rid of the [governmental] mandates that require every payer in the United States, including the federal government, to pay for any drug that has an FDA [Food and Drug Administration] cancer approval," he said.

The mandate was originally well intended — as there was a fear that payers would not pay for "expensive" therapies, he said. Now the "unintended consequence" of the law is that it is "limiting access to cancer care" because of the runaway costs. "With no ability to negotiate, prices can go anywhere they want to go," he said.

Another central problem with costs is the hospital takeover of community oncology practices, he said. The latter are paid about 28% above the cost of their administered drugs. On the other hand, hospital-owned practices are paid 156% more than the baseline cost, based on the linkage to costly hospital beds.

Over the next 5 years, "transparent data" including on drug costs will be forthcoming from analytic efforts that will allow oncologists to "practice more efficiently," he commented.

Newcomer's former employer UnitedHealthcare is now making such data available to clinicians, who can access it under the prior authorization section of their site.

"You have the power to do something about this," Newcomer told the audience. "You are the ones who can make financial toxicity part of your daily lives and do something about it."

Newcomer has equity interest/stock options in UnitedHealthcare. Silver has disclosed no relevant financial relationships. 

National Comprehensive Cancer Network (NCCN) 23rd Annual Conference. Presented March 23, 2018.

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