Rising Cancer Drug Costs Calls for Collaboration and Value-Based Care | PBMI 2025

Collaboration, clinical evidence, data sharing and a focus on patient access are some of the critical things needed to provide those with cancer the best care while managing costs, say panelists at a session at the Pharmacy Benefit Management Institute’s annual meeting today in Orlando.

This will be even more critical as new targeted, innovative and costly drugs become available that extend the life of patients with cancer, said Simone Ndujiuba, Pharm.D., BCOP, senior principal clinical oncology pharmacist at Prime Therapeutics, during the panel discussion. “In 2024, the median annual price of a new-to-market drug was more than $400,000,” she said during the session.

This trend of higher costs associated with cancer treatment and care is expected to continue, and “we will start to see increases in insurance costs and, potentially, greater out-of-pocket spending for members,” she said.

Innovation is exciting and is pushing the boundaries of what is possible, said Kristen Ritchie, Pharm.D., VP of clinical operations at Vivid Clear Rx. “When we see these drugs, we talk about cure and groundbreaking or first of its kind,” she said.

But this innovation is pushing up costs, she said, and all stakeholders need to approach oncology therapies as they would any other high-cost drug: with clinical transparency. “As clinicians, our role is to really take a step back and to look at the actual data, the real-world

evidence, and determine whether there are meaningful outcomes. We really have to see if these therapies live up to the hype.”

Ritchie said the innovative new drugs present affordability challenges for both payers and for patients. To address these issues, pharmacy benefit managers are developing more rigorous prior authorization processes to make sure they are aligned with treatment- and evidence-based guidelines. “We don’t want to necessarily make it a more challenging process or create barriers for access, but we do want to make sure that treatment is clinically appropriate and based on evidence.”

Clinical and real-world data are important, but they don’t always tell the complete story for a particular patient. Jeanine Ewing, Pharm.D., clinical oncology pharmacist at Florida Cancer Specialists & Research Institute, said during the panel

“Clinical trials are designed in a perfect world with a very specific patient and may exclude certain comorbidities,” she said. “But in real life, these are real patients. The challenge is that sometimes real-world evidence may not look as good as the clinical trial, but that doesn’t mean that that’s not the right drug for that patient. And sometimes we do see better outcomes in the real world than what we saw in the clinical trial.”

What is needed, she said, is a focus on precision medicine, which is now part of the standard of care across multiple tumor types. This, Ewing said, requires coverage for next-generation sequencing (NGS) to make sure that patients receive optimal care.

“Oncology regimens require a lot of care coordination,” Ewing said. “People are living a lot longer with cancer, which is incredible, but that has a lot of complexity with lab visits and follow-ups and making sure that we are following these patients very closely so that they don’t get lost to care and we are able to intervene to manage toxicities.”

Ndujiuba said Prime Therapeutics pulls together various types of data to help make better decisions about cancer and high-cost drugs. Prime is developing an integrated medical-pharmacy benefit, which they hope will address concerns about the outcome, cost and complexity of care.

Prime has created a registry that allows the organization to gather the clinical information and the benchmarking data needed to provide forecasting. Several sources of data feed into this registry, including Prime’s own pipeline intelligence and cost utilization information.

As an example, Ndujiuba said, they discussed CAR T-cell therapies. “CAR T is becoming more utilized, although they are still very much in hematologic cancer,” she said. “They are making their way into solid tumors, so eventually there is going to be a noncancer

indication in the near future. We are trying to prepare ourselves and our clients for this new change that we see on the horizon and work to hopefully decrease the financial burden.

“These drugs offer survival where historically we hadn’t seen it. But at the end of the day, we really need to focus on the fact that not everyone gets a cure, unfortunately,” Ndujiuba said.

The goal, she said, is to make sure patients and payers are getting value. And this is where the value-based contracting and risk-sharing become important. “We need to create contracts that can be enforced and that can allow us to continue to help payers and patients drive toward the best care that will yield the best outcomes.”

Ray Parzik, formerly vice president of business development at The Oncology Institute, said that value-based care and risk sharing are solutions for managing costs.

“We all need to recognize, as everyone who’s involved in the healthcare delivery system that touches oncology, the deep responsibility that we have,” he said. “It’s one of the most complicated and challenging conditions that patients are faced with. We all have a deep accountability to do the right thing, to help people get the most effective treatments with the best outcomes in a sustainable way, which requires us to think long term, to expect accelerated adoption of new things, and to come up with a model that creates alignment, active, proactive alignment across all of the stakeholders in the system to do the right thing for patients.”