the finances of cancer care: patient experiences and attitudes...second, financial toxicity impacts...

$: The Finances of Cancer Care: Patient Experiences and Attitudes...Second, financial toxicity impacts quality of life\爀屲2010 National Health Interview Survey \⠀一䠀䤀匀尩$
FINANCIALTOXICITY

Yousuf Zafar, MD, MHSAssociate Professor of Medicine and Public PolicyDirector, Center for Applied Cancer Health Policy

Duke-Margolis Center for Health PolicyDuke Cancer Institute

OF CANCER CARE

THE

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Presentation Notes

THE VALUE PROPOSITION IN ONCOLOGY: DIFFERENT APPROACHES TO UNDERSTANDING VALUE

Mariotto et al, JNCI 2011

HOW MUCH DOES CANCER COST?

0

20

40

60

80

100

120

140

160

180

200

2010 2020

$ Bi

llion

Used with permission

Why?

$100

$1000

$10,000

$100,000

$10

Bach P,http://www.mskcc.org/research/health-policy-outcomes/cost-drugs

$11970 1980 1990 2000 2010 2017

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INNOVATION Drug costs for one month of cancer treatment Red line is median drug costs

BIOLOGICS2003

IMS Institute 2014

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Market share globally of biologics went from 11% in 2003 to 46% in 2013

IMS Institute 2014

BIOLOGICS2013

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between the first quarter of 2006 and the third quarter of 2011. Average quarterly national spending on oral oncologics increased 37 percent

Photo: TV advertisement, BMS

$10,000 a month

Gordon et al, JCO 2017

Mailankody and Prasad, JAMA Onc 2015

COST VERSUS BENEFIT

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The US FDA approved 51 drugs in oncology for 63 indications. p=0.09

“Our results suggest that current pricing models are not rational but simply reflect what the market will bear.”

Mailankody and Prasad, JAMA Onc 2015

Why?

0%

50%

100%

150%

200%

250%

300%

1999 2002 2005 2008 2011 2014 2017Kaiser Employer Health Benefits Survey, 2017

Inflation

Worker earnings

47%

64%

0%

50%

100%

150%

200%

250%

300%


Inflation

Worker earnings

Premiums224%

47%

64%

0%

50%

100%

150%

200%

250%

300%


Inflation

Worker earnings

Premiums

Worker contribution to premiums 270%

224%

47%

64%

$-

$200

$400

$600

$800

$1,000

$1,200

$1,400

2006 2008 2010 2012 2014 2016Kaiser Employer Health Benefits Survey, 2017

0%

3% 4% 5%7% 7%

11%13% 14% 14%

23%

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

FOUR-TIERED FORMULARIES

Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2013

$-

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

0 5 11 17 23 29 35 41 47

Milliman Report, 2017Months from diagnosis

Lung

ColorectalBreast

MONTHLY BANKRUPTCY RATES, WESTERN WASHINGTON STATE

Ramsey et al, Health Affairs 2013

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2.65x greater risk of bankruptcy associated with a cancer diagnosis


Ramsey et al, Health Affairs 2013

2.65xRISK OFBANKRUPTCY

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Ramsey et al, JCO 2015

7,570

79%HR 1.79 (1.64, 1.96)

matched patients

greater mortality risk

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Extreme financial distress

Greater risk of

mortality?

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How can we explain the relationship between financial distress and greater risk of mortality


Greater risk of

mortality

Well-being

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46%

46%

68%Foregone vacations

Cut grocery expenses

Depleted savings

n=254

Zafar et al, Oncologist 2013

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First, we know cancer care impacts financial well being short of declaring personal bankruptcy

50%

39%

73%

willing to declare bankruptcy

willing to sell their home

willing to spend less on food/clothing

Chino F et al, in preparation


Greater risk of

mortality

Healthrelatedqualityof life

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High financial burden:

Quality of lifeamong patients with active cancer and survivors

Zafar et al, JOP 2014

n=1000

adjusted beta 0.06 EQ-5D unit per financial burden category; p<.001

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Second, financial toxicity impacts quality of life 2010 National Health Interview Survey (NHIS) 2,108 patients Patients who reported “a lot” of financial problems as a result of cancer care costs were more likely to rate their physical health (18.6% v 4.3%, P < .001), mental health (8.3% v 1.8%, P < .001), and satisfaction with social activities and relationships (11.8% v 3.6%, P < .001) as poor compared to those with no financial hardship. On multivariable analysis controlling for all of the significant covariates on bivariate analysis, the degree to which cancer caused financial problems was the strongest independent predictor of quality of life. Patients who reported that cancer caused “a lot” of financial problems were four times less likely to rate their quality of life as “excellent,” “very good,” or “good” (odds ratio = 0.24; 95% CI, 0.14 to 0.40; P < .001).


Greater risk of

mortality

Qualityof care

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70%higher likelihood of non-adherence

Dusetzina et al, JCO 2013

Upper 75th percentile >$53/monthaRR, 1.70; 95% CI, 1.30 to 2.22

Zullig et al, J Onc Pract 2013

45%WERENON-ADHERENT

n=254


Greater risk of

mortality

Well-being

Health-related quality of life

Quality of care

?

Financial distress

Non-adherence

Missed appointmentsBankruptcy

Taking fewer medications

Selling property

Spending savings

Delaying care

Declining tests

Buying less foodBuying less clothing

Using other people’s medications

Working longer hours

Cutting out vacations

Using credit

Borrowing from friends or family

Replaced prescriptions with over the counter medications

Spread out chemotherapy appointments

Financial distress

Non-adherence

Missed appointmentsBankruptcy

Taking fewer medications

Selling property

Spending savings

Delaying care

Declining tests

Buying less foodBuying less clothing

Using other people’s medications

Working longer hours

Cutting out vacations

Using credit

Borrowing from friends or family

Replaced prescriptions with over the counter medications

Spread out chemotherapy appointments

INTERVENE

Policy

Provider

Patient

Zafar SY, JNCI 2015

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HOW DO WE INTERVENE: Look at systemic, interpersonal, and individual points of intervention

MANUFACTURERS

GOVERNMENT

INSURERS

HEALTH SYSTEMS

OUTCOMES-BASED PRICING

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Pharma can lower prices

Months

Patients with

disease response

1

79%

12

46%

Prasad V, Nature 2017

Kymriah - $475,000

MANUFACTURERS

GOVERNMENT

INSURERS

HEALTH SYSTEMS

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In Dec 2003, Pres Bush signed the Medicare Prescription Drug, Improvement, and Modernization Act (also called the Medicare Modernization Act or MMA) – NONINTERFERENCE.—In order to promote competition under this part and in carrying out this part, the Secretary— ‘‘(1) may not interfere with the negotiations between drug manufacturers and pharmacies and PDP sponsors; and ‘‘(2) may not require a particular formulary or institute a price structure for the reimbursement of covered part D drugs.

In order to promote competition…the Secretary [of HHS]: 1. may not interfere with the

negotiations between drug manufacturers and pharmacies and PDP sponsors; and

2. may not require a particular formulary or institute a price structure for the reimbursement of covered part D drugs.

Presenter

Presentation Notes

In Dec 2003, Pres Bush signed the Medicare Prescription Drug, Improvement, and Modernization Act (also called the Medicare Modernization Act or MMA) – NONINTERFERENCE.—In order to promote competition under this part and in carrying out this part, the Secretary— ‘‘(1) may not interfere with the negotiations between drug manufacturers and pharmacies and PDP sponsors; and ‘‘(2) may not require a particular formulary or institute a price structure for the reimbursement of covered part D drugs.

$46,868

$7350

16%US Census, 2015

HHS Notice of Benefit and Payment Parameters for 2018

MANUFACTURERS

GOVERNMENT

INSURERS

HEALTH SYSTEMS

Highvalue

Lowvalue

Chernew M et al, Health Affairs 2007

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Value-based insurance design

MANUFACTURERS

GOVERNMENT

INSURERS

HEALTH SYSTEMS

Photo: Nick Veasey, TIME, 2013

PRICETRANSPARENCY

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Health systems can increase price transparency

Policy

Provider

Patient

Zafar SY, JNCI 2015

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HOW DO WE INTERVENE: Look at systemic, interpersonal, and individual points of intervention

Reducefatigue

Preventfatigue

Assessfatigue

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In talking about survivorship model, this is the Ganz approach

Reducefinancialtoxicity

Preventfinancialtoxicity

Assessfinancialtoxicity

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high-value

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Following choosing wisely is something we should do, anyway, but it might help reduce costs for patients, too ABIM Don’t use growth factors for prevention of febrile neutropenia for patients with less than 20 percent risk for this complication. Avoid PET scans in surveillance of asymptomatic patients As we move towards better benefit design, these are the interventions that will hopefully have better coverage

Don’t use cancer-directed therapy for solid tumor patients with:

• low performance status (3 or 4)• no benefit from prior evidence-based

interventions• not eligible for a clinical trial• no strong evidence supporting the clinical

value of further anti-cancer treatment.

ASCO Choosing Wisely

Goals of care

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Effective goals of care discussions - Combined approach to value-based care and personalized/precision medicine� Social workers can prevent but very hard to dig out of debt

Basch et al, JAMA 2017

n=766

5 month improvement in overall survivalHR 0.83 (95%CI 0.70-.99)




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n=299

Do patients want to discuss costs?

52%

Zafar et al, AJMC, 2015

desire a cost discussion with oncologists

19% actually have a cost discussion

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Promoting cost discussions. Most patients want to discuss costs but few do Talking might reduce costs and result in new strategies Challenges: very little transparency can make cost discussions difficult Patient and provider attitude that costs can’t bechanged/lowered….not true

No difficultieswith cost

Want thebest care

My doctorcan’t help

Talked tosomeone else

Not mydoctor’s job

Embarrassed

43%

28%

18%

18%

9%

9%


Why didn’t you discuss costs?

n=299

Proportion with lower costs after cost discussion

57%Zafar et al, AJMC, 2015

reported lower costs due to a cost discussionwith their oncologist

Presenter

Presentation Notes

Promoting cost discussions. Most patients want to discuss costs but few do Talking might reduce costs and result in new strategies Challenges: very little transparency can make cost discussions difficult Patient and provider attitude that costs can’t bechanged/lowered….not true

53%

25%

19%

13%

6%

How were costs decreased?


Referred to financial assistance

MD appealed to insurance

Switched to lessexpensive meds

Changed tests or decreased frequency

Decreased frequency of MD visits

Presenter

Presentation Notes

oncologists should, focus on the value of care delivered oncologists must initiate the conversation physicians must be prepared for the discussion

TALK ABOUT COSTS

KNOWLEDGEBASE

FINANCIAL NAVIGATION

COMMUNITY

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the finances of cancer care: patient experiences and attitudes...second, financial toxicity impacts...

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