Since it peaked in 1991, the cancer mortality rate has decreased dramatically—the rate has fallen over 25%, resulting in 2.4 million fewer deaths in the last 27 years. That great progress, however, has not come without costs.
Rebecca Borgert, PharmD, BCOP, director of clinical oncology product development at Magellan Rx Management, called these costs “unsustainable” during an AMCP Nexus presentation, “Medical Oncology Drug Cost Trends and Innovative Practical Payer Management Strategies.” Borgert and Amy Miller, PharmD, BCPS, clinical pharmacist and program manager of medical pharmacy at Medica, discussed practical ways payers can create sustainable oncology spending.
Borgert and Miller highlighted several key figures that demonstrate how untenable the current situation is for payers:
- The United States is expected to spend a staggering $174 billion per year on cancer care by 2020.
- From 2016 to 2017, the MCO pharmacy benefit drug spend grew by 12%, an average of 21% of the overall pharmacy benefit budget.
- During the same period, the MCO medical benefit increased by 19%, an average of 14% of overall medical benefit budgets.
- The medical benefit spend of oncology for commercial plans was $10.12 per member per month in 2017, the highest single category and over three times the second highest category, crohns disease/ulcerative colitis at $3.01.
- For Medicare plans, the per member per month spend was $24.25.
The oncology market will only grow as the FDA is expected to continue approving record numbers of oncology medications in the coming years.
A practical solution
In 2016, BMJ published an article detailing waste caused by the use of single-use vials. That study estimated wastage amounting to over $3 billion per year. Many drug manufacturers have moved to single-use vials in recent years, citing patient safety, according to Borgert and Miller. The BMJ article was picked up mainstream media outlets and caused a public outcry.
Since that article, the National Comprehensive Care Network (NCCN) updated its guidelines, allowing for biologics and cytotoxic agents to be rounded to the nearest vial size within 10% of the prescribed dose. This was based on research that found a 10% rounding made no negative clinical difference on the safety or efficacy of a therapy. Under these new guidelines, prescribers are able to make more creative use of dosing options, even when only single-use vials are available.
In one example Borgert and Miller provided, a cancer drug is only available in 100 mg doses. If a patient is prescribed 520 mg of the drug every 21 days, the patient is required to use six 100 mg vials—wasting 80 mg of medication in the process. Under the new NCCN guidelines, that dose could be rounded down to 500mg over 21 days—well within the 10% limit, but reducing the need for a sixth vial, according to the presenters.
In one real-world example they shared, similar personalized dosing of a single medication—pembrolizumab (Keytruda)—could result in annual savings of $825 million
Despite the potential for savings, Borgert’s research at Magellan indicated that very few plans were implementing vial rounding, she said. Only 16% of commercial plans and 18% of Medicare plans required vial rounding, while 69% of commercial plans and 61% of Medicare plans had no vial rounding.
Magellan created a program that would automatically detect if a dose would benefit from modification, which would alert a prescriber and ask if the dose could be lowered. Many prescribers (60%) accepted that dose reduction in a pilot program, said BOrgert. In that five-month pilot, the involved plans saw a $748,764, which would amount to about $2.2 million annually—a projected PMPM savings of $0.33.