Dr Mark Fendrick: Setting Cost-Sharing Based on Value, Not Price, in Cancer Care

We should try to remove barriers that are not only in place, but getting higher for clinicians and patients to get evidence-based care, said A. Mark Fendrick, MD, director of the Center for Value-Based Insurance Design at the University of Michigan.

Transcript (slightly modified)

I think there is a role for clinically nuanced or value-based insurance design in oncology given that current plans, both public and private, have what I call 1 size fits all cost-sharing and that you pay for same for every doctor’s visit, every diagnostic test, and every prescription drug. I like to say that Americans pay the same co-insurance for specialty drugs that cure cancers 90% of the time as drugs that never cure a case. That doesn’t make any sense to me; so, I think that this idea of setting cost-sharing based on value, not price, is important to move forward in general, and specifically in the role of cancer care, because cancer is: A. very complicated, B. very emotional, and C. it’s one that exemplifies this idea of our need for a dynamic, or a precision type of benefit design. So, if for instance we have a particular cancer, which has a genetic marker for which there is a specific treatment, I think it should be easy, not hard, for a practitioner to prescribe that targeted therapy, and it should be easy, not hard and not too expensive, for the patient to get that therapy.

When you realize that there are some issues of equity that everyone should have the same type of benefit design, I think that falls directly in the face of what we’re trying to do with precision or personalized medicine. Not that we have to go so far that everyone has a different benefit design, but I’d like to see a benefit design that reflects: A. the amazing innovation that we have going on regarding precision diagnostics and therapies and B. understanding that unless the delivery system evolves to account for this amazing innovation, we’re going to be left behind in a situation that’s not precise or nuanced at all, and that we won’t be able to take advantage of the opportunities that we have as clinicians to improve individual and population health.

In the end, we don’t want to let the perfect get in the way of the good, but we should clearly try to remove those barriers that are not only in place, but getting higher for clinicians and patients to get evidence-based care as outlined say by some well-established guidelines. I think if we started with a few examples in oncology the same way we did with diabetes and heart disease and value-based insurance design in general, we’ll be able to infuse the idea of nuanced or VBID into the care of cancer. So, we might be able to improve access to care, allow providers to have autonomy to provide the evidence-based care they want, but also being very cognizant of the fiscal responsibilities we have toward public and private payers.