Lessons in Cancer Care From NICE and Health Canada at ASCO

On the first day of the annual meeting of the American Society of Clinical Oncology, being held June 3-7, 2016, in Chicago, Illinois, healthcare experts from the United States, Canada, and the United Kingdom, compared and contrasted the care models that are widely adopted in each nation. Placing a significant emphasis on reviewing the value of cancer care, panelists discussed how the National Institute for Health and Care Excellence (NICE) in the United Kingdom, and the Canadian healthcare model, seek to optimize the cost and value of cancer care. Panelists identified opportunities for constructive interventions that could help fill up gaps in the US healthcare system.

United States

Susan Rogers, MD, FACP, Stroger Hospital of Cook County, Physicians for a National Health Program, introduced the US healthcare system. Her talk was entitled, Perverse Incentives and Broken Markets: How Did We Get Here and How Do We Correct It?

Rogers posed the question, “Why do we need a single payer?” But before trying to answer that question, she took a step back to explain some of the basic reasons for seeking health insurance. Rogers said that insuring against health.

• Protects financial assets
• Improves access to care
• Protects health

“The United States has 5 health delivery systems,” Rogers said, listing them as Medicare; Medicaid; private insurance offered to workers where they have to contribute to the premium; healthcare for Native Americans, vets, and the military, provided and delivered by the government (socialist medicine); and the uninsured.

“We are spending a lot of money on healthcare. US public spending per capita for health is greater than the total spending in other nations,” Rogers said, with data showing that US spends significantly greater than the highest amount spent by other developing countries. She added that the increased spending does not guarantee an improvement in infant mortality rates or improve longevity.

So how can access to better healthcare be improved? Rogers pointed out that employment alone does not insure health benefits, because a lot of employers prefer part-time employees, who then do not qualify to receive the benefits. With Medicaid expansion following the Affordable Care Act (ACA), there was hope that disparities in access to healthcare would be addressed. But it was not to be. “If half the physicians are not participating in Medicaid managed care plans, how can patients access care with those doctors?” Rogers asked. Despite the provisions within the Act, the Congressional Budget Office has estimated that 30 million will remain uninsured in 2016 and the number will hover around 29 million till 2019.¹

The ACA has not really helped the US population, Rogers said, because a standard benefits package was not developed under the ACA. While copays and coinsurance were eliminated for enrollees, but it was only for preventive services. “ACA makes underinsurance the norm,” she said. With the average deductibles steadily rising, from $300 in 2006 to $1077 in 2015, medical bankruptcies are significantly higher, especially among cancer patients, Rogers pointed out.

Voting for a Single Payer System

Rogers is a big proponent of a single payer system—she believes it presents several advantages that private plans do not. When a person seeks care at a site, some of the providers may not be in-network, and so when the patients uses those services, they may end up being very expensive, she explained. “A single payer system, on the other hand, will remove provider restrictions and improve access and choice for all.”

While it might cost more to cover everyone (she showed an estimate of $243 billion), a single payer system can be kept funded by eliminating discrepancies in service costs, reducing administrative costs, reducing drug prices could via negotiations, and by introducing a payroll tax instead of a deduction.

Belgium was the first developed country to introduce a government-backed universal health insurance, back in 1945. Subsequently, several countries in Europe and in Asia followed suit.

“ACA is based on private insurance and will not be able to solve patient access issues,” Rogers said. “A single payer will be the only insurance plan that can allow cost control, provide access, and provide better choice.”

United Kingdom

David J. Kerr, MD, PhD, University of Oxford, chaired the panel. Kerr also serves on the advisory board of the National Health Services, Scotland. Kerr began his talk, Across the Pond: Learning from the U.K. Experience, by sharing the definition of “value” by Michael Porter, MD, which says that value should be defined around the consumer, not the supplier. Patient performance, not the volume of services provided, is important.

Kerr listed several enemies of better value cancer care:

• Unwarranted variation
• Inequalities in care
• Inadequate focus on prevention
• Waste of resources
• Patient harm even with high-quality care.

From the societal perspective, “We have an increase in demand and increased burden, with an ageing population. Each medical advance is hailed as ‘breakthrough,’ which raises the hope of patients and caregivers,” Kerr said. He added that our current health models have a demand of transparency and openness from patients and caregivers, but there have been financial constraints imposed by global recession.

Healthcare spending is additionally burdened by treating conditions that were previously untreatable, and also by treating patients who were previously untreatable. Expensive treatments are a sum total of expensive drugs, expensive services such as complicated surgery, expensive imaging, and expensive tests.

Kerr explained that the National Institute for Health and Care Excellence (NICE) guides clinical practice (pathways of care), public health, and HTA decisions. The core values followed by NICE include:

• Input from the public, advocacy groups, and caregivers
• Transparent process and decision making
• Consultation
• Regular review.

Outcomes that NICE considers include cost-benefit, clinical benefit, cost-effectiveness ratio, and health benefit (measured in terms of quality-adjusted life years or QALY). Kerr said that NICE has proposed several ways to curb the cost of cancer drugs:

• Reduce clinical trial costs by 40% to 60% without reducing their quality
• Greater use of adaptive design techniques to reduce trial duration and the number of patients needed
• Data requirements by regulatory bodies should be challenged by oncologists and patient advocacy groups
• Drug costs should be challenged by oncologists and patient advocacy groups

Canada

Ralph Wong, MD, FRCPC, CancerCare Manitoba, had the final presentation. During his talk, North of the Border: Harnessing Market Forces, Deregulation, and Consumer Choice in Canada, Wong explained what works and what does not with the publicly funded single payer system in Canada. “The Canada Health Act of 1984 says that all insured are entitled to the same level of healthcare,” Wong shared, adding that the outcome is debatable. “Individual provinces and territories in Canada have their own agenda, which can result in unequal distribution of healthcare,” he said.

The drug approval can take as much as 2 years in Canada, Wong said, adding that Health Canada needs much longer than the FDA to approve a drug, “although we are at par with the EMA [European Medicines Agency]. Wong pointed to the much smaller market that Canada offers, as the likely reason why drug developers seek approvals in Canada the last.

Health Technology Assessment in Canada

The pan-Canadian Oncology Drug Review (pCODR), established in 2010, conducts the health technology assessment (HTA) for Canada. pCODR offers manufacturers and tumor groups the option of a review before submitting for a Notice of Compliance (NOC) with Health Canada. The HTA review and the NOC can run in parallel.

pCODRhas been documented to recommend 65% of submissions, 14% may or may not be approved, and 21% are usually denied funding. “It’s important to note, however, that oral medications do stand a chance of being paid for by a private insurer. Intravenous infusions could also be funded by private insurers sometimes, offered Wong.

While a significant reduction in the number of days needed for approval has been observed, there is criticism of the overall process. Wong revealed that territorial or provincial governments are ultimate decision makers on when “no means no”, but “yes could mean maybe”. Additionally, decisions could sometimes be inconsistent.

Following pCODR, the Pan Canadian Pharmaceutical Alliance or pCPA) then reviews for cost-effectiveness, a process that involves negotiations with the drug developer to reduce drug costs. “Only those provinces that participate in the negotiations can claim the discounted rate,” Wong said. “But a substantial amount of savings have been noted: C$ 400 million for oncology drugs, annually,” he added.

Reference

1. Congressional Budget Office. Updated estimates of the insurance coverage provisions of the Affordable Care Act. Congressional Budget Office website. https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/49892/49892-breakout-AppendixB.pdf. Accessed June 3, 2016.