Transcript Achieving Value in Cancer Care: ASCO’s Value Framework

Value as a Guiding Principle of
Cancer Care Delivery
Richard L. Schilsky, M.D., FACP, FASCO
Chief Medical Officer, ASCO
Value = Outcomes Achieved
Cost
Value = Outcomes Achieved
Cost
Price is what you pay. Value is what
you get.
---Warren Buffet
Nature of the Problem
• Cancer care costs are growing 15% per year.
• High prices of brand name drugs are creating a difficult
situation for patients and oncologists, who are inadequately
prepared for these challenges.
• Cancer patients are ill-equipped to make difficult trade-offs
between high out-of-pocket costs and very expensive
treatment with measurable but sometimes modest health
benefits.
• Oncologists are often conflicted about how the cost of care
should affect their behavior.
Cost of Cancer Care is Rising
→ $125 billion in 2010
→ $175 billion in 2020
Cancer Care Costs Rising Faster than
Overall Healthcare
Cumulative % Increase
Cancer Drugs
Cancer
Medical
Healthcare
US GDP
Source: Blue Cross Blue Shield Association
Eight of Top Ten Most Expensive Drugs
Covered by Medicare are Cancer Drugs
Top Ten Medicare Drugs 2012
Millions
•
•
•
•
•
•
•
•
•
•
Ranibizumab
Rituximab cancer treatment
Infliximab injection
Injection pegfilgrastim
,
6mg
Bevacizumab injection
Aflibercept 1 mg
Denosumab injection
Oxaliplatin
Pemetrexed injection
Bortezomib injection
$
$
$
$
$
$
$
$
$
$
1,220
876
704
642
624
384
347
309
292
278
.
Source: Moran Company Analysis of Medicare Physician/Supplier Procedure Summary File, 2012. Includes carrier claims only
(physician office and DME). Outpatient Prospective Payment System (OPPS) claims are excluded.
Patients are Bearing More of the Costs
Household Income
Projected family health insurance premium costs and average household income
Annals of Family Medicine: 2012: 10: 156-162
Year
ASCO Value in Cancer Care Task Force
Established in 2007 as the Cost of Care Task Force to define
the challenges related to the cost of cancer care and
develop strategies to address these challenges in the
context of ASCO’s mission
Goals:
• Increase physician education and guidance about cost
• Increase patient education and assistance regarding cost
• Promote high-value medical decision-making
• Assess the value of cancer care
ASCO Efforts to Increase Value in Cancer Care
• Promoting adherence to evidence-based medicine: ASCO
Guidelines
• Commitment to quality improvement: QOPI
• Working with payers: Integration of quality measures into
reimbursement policy
• Cultivating a learning healthcare system: CancerLinQ
• Establishing Clinically Meaningful Outcomes for clinical
trials
• Promoting physician reimbursement reform
• The Value in Cancer Care Task Force
Patient Resources
Goal: To develop communication tools to help patients ask questions
about cost, understand the realities of the cost of their treatment and
interpret cost-benefit.
Managing the Cost of Cancer Care
Patient Information Booklet
An easy-to-read booklet to help patients start and
guide a conversation with their health care team
about coping with costs of cancer care. For
distribution to patients in the office setting as well as
online.
Choosing Wisely Campaign:
ASCO “Top 5” Lists for Oncology
ASCO has issued two “Top Five” lists of interventions that
are frequently practiced but not evidence-based and
likely wasteful
Examples:
• Cancer directed therapy in patients with low
performance status
• Imaging in early-stage prostate and breast cancer with
low risk of metastasis
• Use of white cell stimulating factors to prevent febrile
neutropenia in patients with < 20% risk
Creating Value Through Research
Creating Value Through Research
Begins with establishing and achieving clinically
meaningful outcomes in clinical trials
Goals
To help investigators develop randomized phase III trials that:
-are likely to impact clinical care in the era of molecularly
targeted therapy;
-focus on patient impact, rather than statistical significance
To inspire patient advocates to demand more from trials
To assist clinical trial sponsors and investigators with setting
priorities for pipeline agents
Recommendations for Clinically
Meaningful Outcomes
Minimum meaningful incremental improvement is an HR of ≤0.8
and median OS improvement from 2.5 to 6 months
New regimens that are substantially more toxic than current
standards should also produce the greatest increments in OS
Each Stakeholder Has a Role
Providers: trying innovative ways to lower costs while improving
quality, through mechanisms such as clinical pathways, adherence
to evidence-based medicine, QOPI participation
Payers: looking to assure highest and best use of limited resources
through the development of innovative benefit designs (e.g., valuebased insurance) and pay for performance mechanisms
Patients: mobilizing to promote access through initiatives such as
uniform patient assistance programs, patient navigation, and
education of individuals and families about the cost of care and
expected outcomes of treatment
Manufacturers: finding ways to innovate in the most cost-effective
and efficient ways possible; consider new pricing models such as
indication-based pricing
ASCO’s Value Initiative
• In spring 2013, ASCO Board of Directors engaged in
a strategic discussion on value around the following
statement:
– Increasingly, the desired care for oncology patients will be
assessed on the VALUE of that care rather than the
COST
– This is an opportune moment for ASCO to take the lead in
defining VALUE and suggesting how VALUE should be
integrated into treatment decisions
ASCO’s Value Framework
•To achieve a transparent, clinically driven,
methodologically sound method for defining and
assessing relative value of cancer care options
•The relationship between clinical benefit, toxicity and
cost will be used to assess the value of a new
treatment:
•Clinical benefit (OS, PFS, Palliation, QOL)
•Toxicity
•Cost
ASCO’s Value Framework
• Designed for doctors to use in conversations with
their patients to help inform individual decisions.
• Intended to support consideration of individual
patient circumstances and the best evidence
available on a particular treatment’s clinical
effectiveness, toxicity and cost
• ASCO will not publish scores, rankings, or other
generalizable information about the relative value of
specific cancer therapies.
ASCO’s Value Framework
• Designed to enable comparison of a new treatment
with an existing treatment or, if there is no effective
therapy, with best supportive care.
• Assesses value based on three primary parameters:
Clinical Benefit, Toxicity, and Cost.
• Clinical Benefit and Toxicity are combined to form
a Net Health Benefit Score, then Cost is integrated to
derive an overall Value Assessment for an oncology
regimen.
• Two versions of the framework have been created:
one for the non-curative setting and one for use in the
curative setting.
ASCO’s Value Framework
Pilot tested in 4 clinical scenarios:
• First line treatment of metastatic NSCLC
• Castrate-resistant prostate cancer
• Advanced multiple myeloma
• Adjuvant treatment of HER2+ breast cancer
Current Status
• Gathering feedback from stakeholder groups
• Refining the inputs
• Preparing a communication plan
Thank you!