Are PBMs the Answer to Managing the High Cost in Oncology Care?

A pharmacist who engages in formulary decisions, a medical director for population management for a private health exchange, and an innovations leader at a pharmacy benefit manager (PBM), took to the podium at Patient-Centered Oncology Care, hosted by The American Journal of Managed Care, to discuss cost-saving strategies in oncology and whether benefit managers can play a role in reining-in some of these costs.

“How do we assign value and who will be responsible for the management? We need a new sheriff in town and maybe that will be the PBM,” said Bruce A. Feinberg, DO, vice president of Clinical Affairs and chief medical officer at Cardinal Health.

Glen D. Stettin, MD, senior vice president of Clinical, Research, and New Solutions at Express Scripts said, “At Express Scripts, our customers are mainly tax payers, employers, self-insured patients, and the definition for value varies. Value for some is about access to care and for some it’s about avoiding catastrophe. So we try to help our customers understand the dynamics and how to afford the benefit for everyone and to continue to deliver care for those who really need it.”

Dr Stettin continued that comparing drug prices in the United States with that in other western countries, there’s a big price differential; drug prices are much lower in Europe, for instance, than here and the government makes pricing decisions, vastly different from what we have here. “While I don’t advocate the government to negotiate prices, the private sector needs to fill-in this role,” Stettin added.

What can be the role of employers in this process?

Bruce W. Sherman, MD, FCCP, FACOEM, faculty at Case Western Reserve University School of Medicine, and medical director of Population Health Management Exchange Solutions, Buck Consultants at Xerox, pointed out that a quarter of individuals find their healthcare affordable and these are people with private insurance. “So when we bring it down to the individual levels, it has become such a huge problem for individuals and the employers they work for: it’s a crisis that makes them choose between treatment and going bankrupt,” he said.

“From that perspective, employers really do not have the level of input from the individual’s perspective to influence health plan or PBM perspectives, Dr Sherman said. Advocacy groups could be in a better position to do that. Employers are relying on PBMs to be the hired gun to provide the level of control for healthcare service delivery so costs are not excessive for benefit enrollees.

Stacey W. McCullough, PharmD, senior vice president, Pharmacy, Tennessee Oncology, explained, “Physicians don’t have it in their make-up to have financial conversations with their patient. It’s hard to talk to the patient about that extra week of therapy when they really want to attend that wedding.” These kind of choices that a patient may have to make are difficult for an oncologist to discuss with the patient.

Dr McCullough explained that the pre-authorization (PA) process and the number of FTEs that they have to maintain, indicate that access to care continues to grow. “We have 3 divisions within the clinic side; someone gets the PA and it rolls to foundation assistance or co-pay assistance. The administrative burden here is quite high. Also, with patent expirations, non-branded generics may not come with a big price difference compared with the branded product.” However, co-pay assistance could be a problem for generics, she said. “This little offset can significantly increase patient cost.”

Dr Stettin defended the position that PBMs sometimes have to take. “Our job is to make drugs affordable. We did PA on 5 million of 1.3 billion prescriptions last year. Not approving therapy, sometimes folks do not follow evidence-based treatment; other times they are using experimental therapies—and we feel for the patient because they are desperate, but there are rules and the intent of the health plan is to pay for therapy that is safe and effective. We have to enforce this policy but it makes us unpopular,” he said. The resulting savings can make treatment affordable for everyone, he said, offering the thousand-foot view of the current healthcare conundrum.

Dr Sherman described the situation saying, “I think we are headed for a collision course between rapid growth of treatments and the society unwilling to pay for them. About 50% of US working adults earn less than $30,000 annually. With the incredible costs of available treatments, people have to make tough decisions on personal bankruptcy as an outcome of the need for treatment.”

Dr Sherman wants physicians and care teams to consider this, and wants to encourage patients and their family members to have frank conversations on cost of treatment with their treating physicians. “We’ll be seeing more of this in the coming years,” he added.

“I think there’s that combustion in that while some steps of PA are definitely necessary, there may be an educational factor somewhere,” said Dr McCullough. “While physicians know something is expensive, they may not know the exact distinction. We have not tried to bog them down with the details. EMR [electronic medical record] and pathways that include a protocol analyzer may be something physicians may benefit from and might even want to know.” In her opinion, the current situation might be the result of unintentional use of the more expensive drug by a physician, being blind to the cost differential.

“There are no ready answers here; there are ways to mitigate this by approaching these new treatments by aligning. There are no easy answers, however. Currently, we have science and technology growing at a much faster rate than wages and, consequently, the affordability gap is rapidly growing,” said Dr Sherman.

Dr Stettin concluded that from a patient-centric standpoint, we need to think of what people will do. “Ask them, what is fair value for the drugs? We need affordable benefits for everyone. While I don’t see PA going away, there will be transformation in terms of instant decision rendition, primarily for pharmacy benefit; we are getting there with medical benefit. While none of us like it, it saves a lot of money. We are working on a rationale for the best way to communicate the information,” Dr Stettin said.