payers insights into future oncology management

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Payers Insights Into Future Oncology Management By Rhonda Greenapple MSPH, President, Reimbursement Intelligence

Reimbursement Intelligence, a nationally recognized market research firm, conducted research with 50 of the top-ranked man-aged care health plans to better understand the current and future dynamics in oncology management and evaluation of pipeline thera-pies relative to current treatment paradigms. This article reviews key insights from the survey regarding new care models and payer evalu-ation of 3 new non-small cell lung cancer (NSCLC) compounds.

The RIQ 2011 ASCO Special Report: Payer Reactions to Highly Anticipated Innovations and Clin-ical Data Presentations obtained critical intelligence from both com-mercial and government managed care health plans covering over 100MM lives. Medical and Phar-macy Directors were represented equally to ensure both perspectives in evaluating therapies.

Four key tumor types: breast, NSCLC, melanoma, and hemato-logical malignancies were covered by the respondents—all of whom participate in their P&T commit-tee meetings. This article will only focus on the NSCLC section of the report. Utilizing NCCN Guidelines and other evidence-based medicine guidelines, payers work towards managing use of less costly thera-pies and ensure that the most effi-cacious treatment for a patient’s

tumor type and staging is being used.

Quality Initiatives and New Care Models

Payers recognize NCCN guide-lines in determining coverage for an oncology treatment with 90% using Category 1 and Category 2A recommendations (Figure 1). Payers are also developing quality initia-tives where they work with oncol-ogy practices to gather data and outcomes based on accepted guide-lines. According to our survey, over half of the respondents indicated they implemented quality initia-tives in oncology with either NCCN Quality Measures (35%) or with ASCO Quality Oncology Practice Initiatives (25%).

Under the Affordable Care Act, Accountable Care Organizations (ACOs) are considered to be bring-ing a new model of care for Medi-care beneficiaries, and are, in effect, an integrated system that attempts to eliminate fragmented care for Medicare beneficiaries. ACOs are a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordi-nate care for the Medicare Fee-For-Service (FFS) beneficiaries they serve. They must agree to accept responsibility to serve at least 5,000 Medicare beneficiaries for at least 3 years.1

Patrick Cobb, MD, Chairman of Community Oncology Alliance

Source: Reimbursement iQ: 2011 ASCO Special Report to Latest Clinical Trials

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ON-CONOMY(COA) and the COA Policy Com-mittee, and Ted Okon, Execu-tive Director of COA, outlined the challenges for oncologists in the advent of ACOs, in a recent article on OncologyStat.com. According to Cobb and Okon, “An oncology pro-vider participating in an ACO will be under enormous pressure to sim-ply control or reduce costs. Support-ers argue that ACOs are different from HMOs, in part because they are not just about cost-savings—quality measures must be satisfied. However, there are no quality mea-sures for cancer treatment. Fur-thermore, although there is a nod to quality, no one should kid them-selves—ACOs are really all about saving money.”2

Our survey validates the COA leaders’ concerns showing that increasing use of lower cost treat-ment alternatives ranks highly as does improving overall spending tracking (Table 1) when the respon-dents were asked to rank in order of importance primary drivers for partnering or forming an ACO.

Under an ACO structure, our survey indicates that health plans anticipate more increased price concessions, including more aggres-sive contracting with manufactur-ers (35% of respondents) or more aggressive pursuit of manufactur-er rebates (10% of respondents). Health plans designing ACOs acknowledge that managing oncol-ogy therapies will have challenges including reduction of overall med-

the cost burden to payers. Unfortu-nately, the 5-year survival rate for all patients with NSCLC was only 15% in the period 1995-2005.3 With new treatment options and com-bination therapies, NSCLC thera-pies will continue to be a focus for oncology management (Table 2).

ical costs and creation of a viable risk sharing structure.

Lung Cancer ManagementIn certain cancer types such

as NSCLC, treatment options are expanding, but with these clinical gains also come the expansion of



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Most new oncology molecules are priced at $5,000 per month or more, and recently one newly approved cancer therapy broke the $100,000 per year threshold. Several NSCLC clinical studies involve combina-tion therapy with biologics as well as second- and third-line therapies. In a recent New England Journal of Medicine article, Thomas Smith, MD, and Bruce Hillner, MD, con-sider whether patients who have progressive disease after 3 consec-utive regimens should be switched to palliative care specifically where there are lung and breast cancer guidelines.4

However, payers understand despite the drug cost that there is still a need for effective treatment options for NSCLC. In our RIQ 2011 ASCO special report, 80% of payers cover the use of Tarceva [erlotinib; Genentech] and Avastin [bevacizumab; Genentech] in non-squamous NSCLC with only 5% placing any restrictions.

The report also provided feed-back on 2 new targeted therapies: astruprotimut and empepepimut. Astuprotimut [MAGE-A3 ASCI; GSK] is a targeted immunother-apeutic agent designed to trigger a specific response against tumor cells expressing MAGE-3 antigen, presenting in 30%-50% of NSCLC patients. In a Phase 2 trial, there was a 27% reduction in relative risk of cancer recurrence following sur-gery vs placebo.

Emepepimut [Stimuvax; Mer-ck] is a vaccine against cancer cells expressing MUC-1 antigen, which is present in 74%-86% of NSCLC patients. In a Phase 2b trial with advanced NSCLC (stage IIIB and IV)

results showed a median survival of 30.6 months with Stimuvax vs 13. 3 months with best supportive care.

Payers reviewed both products’ trial data and Stimuvax effica-cy rated higher than emepepimut (Figure 2).

More important, 80% of pay-ers rated Stimuvax survival data significant or highly significant. However, the majority of payers expect these products to be priced equal to or higher than Avastin (Table 3).

Another product in the pipeline, [crizotinib; Pfizer, Inc], is an oral, selective, small molecule inhibi-tor for patients with NSCLC who express the EML4-ALK gene muta-tion. Approximately 3%-5% of individuals with NSCLC have this mutation (which represents about 6,000 to 10,000 patients in the United States). Most recent data presented at the 2011 ASCO meet-ing from a nonrandomized, retro-spective Phase 1 trial showed that patients who are ALK+ receiving crizotinib as second- or third-line



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therapy vs ALK+ patients in the control group who had previous-ly received standard of care chemo-therapy (pemetrexed or docetaxel) or erlotinib had a 1-year overall survival of 70% vs 44%, respective-ly; and 2-year overall survival of 55% vs12%, respectively.

Payers project using crizotinib with 23% indicating first-line ther-apy for EML-ALK gene fusion positive patients, and 42% for sec-ond-line therapy for EML-4-ALK gene fusion positive patients after failure on chemotherapy alone.

Diagnostic Value Manufacturer’s research and

development will continue to iden-tify biomarkers and gene selectiv-ity to increase targeted therapies in NSCLC. New diagnostics will be valued by payers as the tests help ensure the right treatment reach-es the right patient thus increas-

ceivable that lung cancer can become a chronic disease with long-term maintenance therapy. With more treatment options and combi-nation therapies, guidelines and evidence-based medicine will be critical in containing costs and ensuring appropriate care. RI

ing quality of care while reducing costs. According to the report, pay-ers recognize that diagnostic tests will reduce use of ineffective drugs and increase appropriate treatment (Table 4).

In ConclusionPayers have traditionally not

managed oncology treatment choic-es since care is so individualized and many patients face life-threat-ening conditions. However, payers are looking to new models like qual-ity initiatives to allow for better use and adherence to guidelines to pre-vent unnecessary or ineffective care. Many branded lung cancer therapies are over $50,000 per year which is an increasing burden for health plans. However, pipeline therapies for NSCLC are offering the hope for breakthrough thera-pies that can improve the overall survival for patients. It is not incon-

1Summary of Proposed Rule Provisions for Accountable Care Organizations Under the Medicare Shared Savings Program, Center for Medicare & Medicaid Services, April 2011.2Cobb P, Okon T. Just ‘who’ is the oncologist accountable to in an accountable care organi-zation? September 7, 2010. www.oncologystat.com/viewpoints/cancer-policy-forum/Just_Who_Is_the_Oncologist_Accountable_to_in_an_Accountable_Care_Organization.html 3CDC and Prevention, Cancer Incidence and Mortality Rate, 1995-2005.4Smith T and Hillner B. Bending the cost curve in cancer care. N Engl J Med. 2011;364:2060-2065.

About the Contributor

Reimbursement Intelligence is a nation-ally recognized market research firm specializing in Managed Markets and reimbursement. Our clients include biotech, pharma, and medical device as well as financial analysts and institutional investors. To obtain a copy of the RIQ Special Report, please call 973 805 2300 or email [email protected].

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