In 2012 and 2013, the American Society of Clinical Oncology (ASCO) published 2 sets of 5 key opportunities to improve value in cancer care as part of a multispecialty project, called Choosing Wisely.1,2 As a supervisor for a process that reviewed more than 15,000 hematology and oncology treatment requests in 2013, we were able to observe oncologists who followed ASCO’s advice, and those who were either unaware of Choosing Wisely or who chose to disregard it. Although the recommendations were not universally followed, they were a tremendous step forward in advancing value-based oncology treatments.
Of the initial 10 ASCO recommendations, none addressed the concern that drug and chemotherapy pricing was a key driver of oncology cost inflation. In June 2015, ASCO published its new conceptual framework to assess the value of new cancer treatments from the perspectives of efficacy, side effects, and cost.3
On a parallel track, Peter B. Bach, MD, MAPP, Director, Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center (MSKCC), NY, and colleagues have developed an interactive research tool called DrugAbacus that tackles the perplexing and complicated issue of estimating the relative value of specific oncology drugs.4 This system was unveiled at the 2015 ASCO meeting. Dr Bach and MSKCC have been the clear leaders in the argument that exponential drug pricing increases in oncology must be changed.4
From a health insurance perspective, the first question may be whether very high-priced drugs are likely to be low in value. Certainly, if the high price is not accompanied by high results, that would be an insurance concern, a concern of patients paying their cost share, and possibly a concern of the biggest payers, the US government and the states. In a speech Dr Bach made in May 2015,5 it is clear that he does not think the government is the solution, nor that the government will generate a solution anytime soon for this problem. However, governments do not examine patients and do not design oncology treatment plans.
A brief examination of the amazing DrugAbacus value tool shows that at least 4 drugs have massive expenses above their values as assigned by DrugAbacus.6 One cannot envision a treating oncologist using this tool and then not thinking twice about the value of using any of these 4 drugs.
What ASCO and MSKCC are doing is creating something new and needed, a “market” in oncology care. If oncologists follow Choosing Wisely and are more judicious in using emetic drugs, pegfilgrastim (Neulasta), and positron emission tomography scans, the prices may not fall, but certainly the units will fall. Then the national expense will also fall.
When MSKCC refused to use pembrolizumab (Keytruda), the manufacturer reconsidered the price. In hepatitis C, one large pharmacy benefit manager negotiated price concessions for ledipasvir plus sofosbuvir (Harvoni), with the implied threat that minus the concessions, the business could be directed to competitors’ drugs.
ASCO and MSKCC are to be strongly applauded for their innovation and effort. Without some generation of market leverage, drug manufacturers will indefinitely maintain what Dr Bach quoted in his May speech, “unconstrained pricing power—the mess we have now.”5
