Ryan Haumschild, PharmD, MS, MBA: As we look at total health care resource utilization, Jay, I’m going to come to you on this question because it is important. When we look at total cost of care of multiple myeloma, there are transplants, there’s high acquisition cost. There’s adverse effect management. There’s high outpatient utilization as well as patients being admitted due to some of these rate-limiting toxicities. As a payer, talk me through, how do you evaluate the economic impact of multiple myeloma, and what type of data do you evaluate? Do you evaluate just the pharmacy side? Do you evaluate the medical side and pharmacy side together? And how are you going to start leveraging that to make treatment-level decisions?

Jay Weaver, PharmD, MPH: I appreciate the question. It’s insightful that we’re at this sort of inflection point in health care where we have more data at our fingertips than ever before. The advent of electronic medical records, EMRs, have given us better insight more quickly into information both from the pharmacy and the medical side. It’s interesting as we’re drowning in data how to make it meaningful and use it to drive some of these discussions. It’s been the promise of health plans for many years that they were somehow integrated between medical and pharmacy, that if we brought those things together, there was some synergy that somehow 1 plus 1 equaled something more than 2. I’m not sure that we’ve always delivered on that promise. Those departments have been very siloed in some cases, with decisions being made in one place or the other.

The pharmacy industry, the PBM [pharmacy benefit manager] industry especially, moved a lot faster than medicine in terms of how they thought about certain problems and how they began to look at therapeutics and the cost and all those things. We went far out quickly in terms of how we managed medications that were in that pharmacy channel, especially as the high-cost oral therapies came along, and didn’t give a lot of attention to some of the high-cost infusion products and some of the costs there until probably just 3, 4, 5 years ago that this has come to light. And that’s been catapulted, we talked about the CAR [chimeric antigen receptor] T inhibitors for instance. As we started seeing several $400,000, $500,000 therapies, it got folks’ attention. And instead of simply putting it into a pharmacy somewhere and managing through a specialty benefit or something, it forced us to see these don’t necessarily fit there terribly well. We need to think about this holistic problem and how do those therapies fit together.

I’m not a cancer specialist, I’m a drug information guy, and I remember being struck, having studied FDA law and other things for many years, the first time we had, somebody mentioned Revlimid [lenalidomide] earlier, the first time we had a targeted therapy end up in somebody else’s label. The manufacturer of product B didn’t go get an indication for their product. Product A has a label and mentions product B in it, and it’s a branded high-cost therapy. I thought, wow, what do we do with this? How do we consider this in labeling because it’s in someone else’s labeling? That made us rethink this problem, especially given how many of those sorts of combination regimens were crossing over the benefit channel. If I’m going to spend a lot of money in channel A, whether that’s medical or whatever, or radiology, or a drug, and I’ve got a complementary therapy in the other channel, did I actually buy both of them? Did I make sure that someone’s getting both those therapies to get the maximal value out of that? Instead of the old way of utilization management, thinking about blocking this therapy, that therapy, now we’re thinking, we need a commission of care to make sure that if we’re going to pay for these investments, these high-cost therapies, we’re going to get all the value out of them. And then begin thinking about what is that value. Are we seeing outcomes? Are we seeing the data come back to show that these therapies are doing what they say?

I will jump in and put my DI [drug inspector] hat on through the lens of the cancer people here, we’ve seen a number of therapies that haven’t delivered on all their promises. We’re at this point where there’s sort of a tsunami of therapies that we’ve had to rethink which populations of patients we should use them in. It’s a fun time in this industry to have technologies that are life-saving. I tell people around my plan all the time that some of this is share of wallet. We’re moving therapies from paying for high-cost medical outcomes and hospitalizations and things into being able to pay for technologies, either tablets or infusions, to help change the curve of that. In some cases, we’re buying life, and we’re buying quality of life and those things. We have to come up with new ways to think about these problems, and then to capitalize on keeping those members on a longitudinal basis within our plan to see the value that we brought.

Ryan Haumschild, PharmD, MS, MBA: Jay, a question for you, because you did a great job describing the way you evaluate therapies, and almost your excitement of new therapies coming forward. You as a payer see this as a great way to improve health outcomes, which I appreciate, because at the end of the day, we’re all working to improve the patient care. But there’s one reality we’re seeing as we see more BCMA therapies move up further and bispecifics, is we are seeing more cost creep. But it’s inevitable. And I like how my colleagues mentioned it earlier, that we might have initial high cost, but we might have better outcomes over time, or less cost due to health care resource utilization. That’s good and something for us to recognize, but it’s hard to ignore the economic burden in multiple myeloma, especially as these patients live with a more chronic disease, and have longer survival, they are going to transition through multiple lines of therapy. Now when we look at the refractory space and relapse space, we know that there are CAR T options available, and there is additional therapy there. For you as a payer, are there ever going to be times where you feel like the economic burden is going to be so great that you may have to stratify patients and almost create step through therapies, or create more specific pathways for treatment based on a patient’s background? Just to make sure that not everyone has overutilization of these agents?

Jay Weaver, PharmD, MPH: You’ve put it well, and I would even take it one step further, that we’ve thought about in the past these pathways more for just the sake of utilization management and how to steward resources. It’s moved beyond that a little, and someone brought up earlier adverse drug events, and some of these conditions that present in later decades of life, and therefore, the more frail and elderly might not tolerate some of these therapies. Really matching and homing those therapies into the folks who are most likely to receive the value, or least likely to experience an iatrogenic disease from those therapies, is part of our charge there, so that stratification you mentioned is critical. I would agree that the cost is also a factor in that. We want to make sure that we are leveraging the right assets for the right people and the ones who we are going to see the best benefit from. I will say, and this is not pejorative in some way, it’s not a negative, but if we think about some of the ways the costs are built out for some of these products, they almost assume an ideal response rate for a therapy, and the best possible outcome of that therapy, and the biggest offset of all sorts of resources in the cost/benefit buildup and ultimately, the price of these therapies.

What we know is what we see in trials is not what we see in the real world. Someone mentioned adherence earlier, and it’s noteworthy that there are many reasons that people don’t do quite as well out in the community as they did in clinical trials when people are watching them, and to stay in that trial they need to stay on the drug, and we’ve got all sorts of extra resources. So in that, as we think about the real-world performance of these therapies, relative to that price point that was set on very idealistic adherence and outcomes, we know that there’s a gap. And we need to bridge that gap. Some of the tools and stratifications that you’re talking about will help with that. Then framing the use of clinical pathways could be a tool to begin to standardize the experience to hopefully gain the most impact of those therapies that we can.

This transcript has been edited for clarity.