IO therapies hold great promise, but often come with high price tags. How do payers feel about these medications?
Sheldon J. Rich, RPh, PhD
Immuno-oncology (IO) therapies, such as nivolumab (Opdivo), atezolizumab (Tecentriq), or pembrolizumab (Keytruda), have made waves throughout healthcare for their innovative-and often effective-methods of treatment. But along with the buzz about efficacy comes a question of pricing and value, with payers asking, “What is the value of this highly-specialized therapy?”
That’s the question Sheldon J. Rich, RPh, PhD, President of SJR Associates, hopes to answer. At the upcoming Oncology Market Access Strategy Summit, February 20-21, 2019, in San Francisco, Rich will be presenting on his perspective.
His talk, “Managed Care and Specialty Pharmacy Considerations for Immuno-Oncology Therapies,” will focus on the increasing role IO therapies play in healthcare, as well as how pricing and value can be aligned. Rich will also touch on issues of prior authorization, patient assistance, and care coordination, giving examples of how payers are managing these therapies in the real world and outlining future opportunities and challenges in the space.
Managed Healthcare Executive spoke with Rich ahead of his talk for his insight on what the talk will cover and some of his thoughts on IO therapies.
Managed Healthcare Executive (MHE): Why should IO therapies be on healthcare executives’ radar?
Rich: Individual patient costs are high for IO therapies. Healthcare executives should be concerned with providing the best care in the most cost-efficient manner. The IO therapy market is quickly evolving and it would behoove all parties to use all resources at their disposal to stay on top of the advancements being made with these therapies.
MHE: What are the pricing and contracting approaches for IO therapies? What is different from other chemotherapies?
Rich: Historically, there has not been a lot of contracting taking place in the oncology space, however with more new product introductions and competitive products this is changing.
MHE: What is different for patient assistance with IO compared to other oncology therapies?
Rich: IO therapies have a unique set of side effects and concerns and patient education is key to minimize side effects and toxicities and maximize outcomes.
MHE:What is different for care coordination with IO compared to other oncology therapies?
Rich: A team structure utilizing various members of the healthcare team is critical to assure positive outcomes with IO therapy.
MHE:Are there challenges with prior authorization for IO/chemotherapy combinations that differ from IO or chemotherapy?
Rich: Combination therapy is typically very costly, and payers want to maximize positive outcomes for the best possible price. It is also imperative that rational use of any IO/chemotherapy combination be supported by good clinical evidence.
MHE:What will be the future challenges for IO therapies?
Rich: The high cost of newer therapies-especially therapies like the CAR T-cell therapies-while having the potential to be curative come with a whole host of cost and therapy considerations. Among these are the durability of response, the selection of the appropriate patient likely to benefit from the therapy, the limitation on the number of sites having the expertise to administer these therapies, and the sustainability of the healthcare system to pay the cost of these therapies.
Another interesting point to note is that the ACA removed lifetime maximums from insurance policies. If the ACA is struck down, that provision may not survive, thus putting the public at risk for paying for these multi-million-dollar therapies.