U.S. cancer drug policy is scandalous

By Joshua Cohen, Ashley Malins and Zainab Shahpurwala
Health Affairs, April 2013

Abstract

In Europe drug reimbursement decisions often weigh how new drugs perform relative to those already on the market and how cost-effective they are relative to certain metrics. In the United States such comparative-effectiveness and cost-effectiveness evidence is rarely considered. Which approach allows patients greater access to drugs? In 2000–11 forty-one oncology drugs were approved for use in the United States and thirty-one were approved in Europe. We compared patients’ access to the twenty-nine cancer drugs introduced into the health care systems of the United States and four European countries (England and Wales, France, Germany, and the Netherlands). Relative to the approach used in the US Medicare program in particular, the European evidence-based approach appears to have led to reduced prices for those drugs deemed worthy of approval and reimbursement. The result is improved affordability for payers and increased access for patients to those drugs that were available. The United States lacks a systematic approach to assessing such evidence in the coverage decision-making process, which may prove inadequate for controlling costs, improving outcomes, and reducing inequities in access to care.

From the Discussion

The current method in the US Medicare program of seemingly “muddling through elegantly” appears incapable of striking a fiscally sustainable balance between cost and access, particularly with respect to cancer drugs. Spending on cancer treatments continues to grow at double-digit rates annually, which in turn has led to much higher cost sharing for patients. This has an impact on the kind of treatment that Medicare beneficiaries get because patients with better insurance, or those who are able to pay higher out-of-pocket costs, have better access to care.

Conclusion

Medicare policy makers might do well to draw lessons cautiously from the experiences of health care systems that have integrated clinical and economic evaluations into decision making. Should the US Medicare program decide to move toward more systematic use of comparative effectiveness findings, there are formidable challenges inherent in the US system that will need to be addressed.

One challenge is payer fragmentation. The diffuse system of payers would probably make the uptake of comparative effectiveness evidence segmented and uneven.

A second challenge is the view of many oncologists that resources are unlimited. In a US-based survey conducted in 2009, nearly 80 percent of oncologist respondents said that patients should have access to “effective” care regardless of costs. An implied cost-effectiveness threshold was calculated at $300,000 per quality-adjusted life-year. Needless to say, having Medicare pay for every cancer treatment that cost up to that amount would not be feasible in the long run.

There is room in the US Medicare program for more systematic and coordinated methods and a process for developing and implementing evidence relative to cost and cost-effectiveness. The immediate goal should be to encourage a more evidence-based process of decision making by closing the gap between what providers, payers, and policy makers know in pharmaceutical care and what they do.

http://content.healthaffairs.org/content/32/4/762.abstract

Comment:

By Don McCanne, M.D.

Cancer drug policies in the United States, compared to other nations, result in higher drug costs, intolerable out-of-pocket costs, and inequitable access to the drugs – preventing many people from receiving comparatively effective drugs, while enabling others to have very expensive drugs of little or no value, wasting our healthcare dollars.

We can do far better in establishing drug policies that are evidence-based and cost-effective based on quality-adjusted life-years. First we need to elect leaders who care more about us, as patients, than they care about kowtowing to the pharmaceutical giants and other special interests.

When it comes down to it, it really is our fault when we fall for the government-can’t-do-anything-right malarkey, and elect those who disseminate this false notion.