Access to Oncology Drugs

Bruce A. Feinberg, DO: So, Bruce, you’ve been involved in a lot of these different pilots.

Bruce J. Gould, MD: Yes, sir.

Bruce A. Feinberg, DO: Is that $165 really touching the cost of what’s involved?

Bruce J. Gould, MD: As long as Medicare doesn’t compress other sources of revenue for us—which they’re trying to do. Through the Part B model, they’re taking ASP (average sales price), what should be ASP + 6, but, in reality, because of the sequestration, is ASP + 4.3, and now they’re trying to reduce that further to ASP 0.85 + $16.52 per drug. Again, that’s a big cut to the practice revenues.

John L. Fox, MD, MHA: And to your point earlier, Bruce, I think you’re choosing drugs based on what you think is most efficacious.

Bruce J. Gould, MD: Right.

John L. Fox, MD, MHA: Medicare’s strategy seems to be predicated on evidence that physicians are choosing drugs based on how much margin they can make. I’m sure that happens, but I don’t know if there’s any empiric evidence that suggests that that is widespread. My concern is, at the end of the day, if you aren’t infusing chemotherapy, what’s left? It’s the high-cost hospitals.

Bruce J. Gould, MD: Right.

Bruce A. Feinberg, DO: In a program we did with a mid-Atlantic insurer, we actually created a medical home model in which all of the reimbursement for drugs was moved out and moved into evaluation and management (E/M) codes. In that model, where the doctors were making nothing off the drug, they didn’t change their pattern of care. They did exactly the same thing, which goes to your point that if you follow the guidelines, it is pretty prescriptive. You start to have variation—second-, third-line, and beyond—but in the adjuvant patient and in the first-line metastatic patient, there’s not a great deal of variation because the evidence is so powerful.

John L. Fox, MD, MHA: That was our experience, too. In non—small cell lung cancer, in particular, the 5 different practices who chose their own preferred regimens chose almost identical first- and second-line regimens, and they weren’t the most expensive therapies. So, again, it’s kind of confusing about what Medicare’s strategy is.

Bruce J. Gould, MD: The point is there’s really no data to back up their hypothesis. In fact, the data is just the opposite. Bruce mentioned the project he was involved with. Our practice was involved with the UnitedHealthcare Episode of Care Program in which the chemotherapy revenues were disassociated and paid in an episode-of-care fee. The pilot programs were compared to a database from United, and it turns out our expected cost of care was supposed to be around $90 million.

We came in at an actual cost of care at $60 million for a $30-million savings compared to what was expected. Yet, our drug use was higher despite the fact that we weren’t being paid more based on the amount of chemotherapy that we gave the patient. Again, this is another study that speaks against the Centers for Medicare & Medicaid Services’ hypothesis that doctors are motivated by drug profit.

Bruce A. Feinberg, DO: Tying it back to orals now: is the whole cost story creating an impediment to the prescribing of orals? Are there patients who are turning down the option because it’s not an affordable option for them? Do you think there are physician practices and specialties who are just finding themselves, because they’re not dispensing, unable, and granted?

A lot of it is prescribing, and there is some latitude there. It could be a second-line EML4-ALK (echinoderm microtubule-associated protein-like 4—anaplastic lymphoma kinase) or a second-line EGFR (epidermal growth factor receptor) after a first-line failure—but you could go to chemotherapy because it’s not clear which is better. We don’t have the head-to-head trials. Do you think that there are real impediments to orals at this point, based on some of these issues that we discussed?

Bruce J. Gould, MD: I would say, for the most part, no (from the patient’s perspective). This gets to the unreimbursed care that a lot of practices deliver. All of us doctors, our hearts bleed for the patients and the fact that they’re in a really tough predicament, and I think most high-quality practices go out of their way to help the patients, even at their own expense. In our case, we certainly scour the patient foundations to come up with money to help these patients get their drugs. We send them for financial counseling and try to get free drugs from the drug companies in order to get these patients the care that they need.