
Important numbers to know for the next 5 years.
You’ve likely seen the advertisements for the cancer drugs Keytruda & Opdivo. Drugs like these have been fueling the record setting per patient treatments costs that approach $300,000. Cancer drugs are the largest contributor of growth through 2028 per IQVIA’s “The Use of Medicines in the U.S. 2024”. Cancer treatment, which was disrupted early in the pandemic, has seen a sharp rise, especially in clinics and doctor’s offices, per the report. Knowing the significant need ahead combined with the robust and cutting-edge medicine in the drug pipeline, plan sponsors need to act now to provide access to these hopefully life changing therapies without breaking the budget.
IQVIA summarizing the barriers plan sponsors and members face financially with this devasting diagnosis, “Oncology most often represents products that don’t compete directly with each other or that are paid via the medical benefit where there is less rebate negotiation generally and specifically doesn’t take place in Medicare part B, and yet net prices are 24% below list price, largely because of the influence of the 340B program.” Those messages in the market lead to plan sponsors being told they cannot manage oncology; we must accept it. I find these statements puzzling. Doesn’t a plan sponsor have the same fiduciary obligation to ensure appropriate care and fair pricing? The stakes, both clinically and financially, are high in these situations. I would argue that in these emotional moments, this can be the perfect opportunity to be a healthcare advocate for your member in need.
Here are some management considerations to help the member and plan stay be in the best position possible to manage this wave:
Robust clinical criteria for use must be prioritized. Who is managing your prior authorization/pre-certification process? This is a golden opportunity to provide members with a true, independent 2nd opinion that the carriers may not be meeting your expectations. Aside from the basics of dose optimization, duration necessity and contraindications, precision medicine and pharmacogenomics are going to be required for the pipeline drugs. Does your current process meet IQVIA’s clinical management expectations for the complex molecules, genetic sequencing and key timing of interventions to promote the best health outcomes?
“New modalities are expected to drive oncology spending with cell and gene therapies, bispecific antibodies, radioligands and antibody-drug conjugates making up an increasing part of novel medicines in both solid and hematological malignancies.
In addition to the flow of more biomarker-driven therapeutic choices, the use of next-generation sequencing technologies (NGS) is expanding, which can test for multiple potential mutations at once and guide therapy selection more precisely, including the timing of shifting lines of therapy for more optimal results.
In addition to robust innovation, the continued wider use of novel immunotherapies, shifting to earlier lines of therapy and used for longer treatment durations, are bringing significant survival benefits to many patients.”
Formulary selection leveraging lower cost biosimilars is imperative. Biosimilars in cancer have already experienced a significant uptick between 2020-2022 with bevacizumab, rituximab, and trastuzumab driving significant savings without safety or efficacy issues. Confirm your carrier is not allowing the reference products and/or not passing through the savings. IQVIA’s slowing growth later in the forecast to 8% is in large part due to the biosimilar introductions of Opdivo and Keytruda contributing to reduced brand spend in oncology.
Direct contracting, 340b, and clinical trials will offer unique sourcing opportunities. Market disruptors like Mark Cuban’s Cost Plus Drugs already offers significant savings for some tried and true therapy options.
Per IQVIA, “over the next five years, spending is expected to increase 105% on a net basis…” due to “more than 100 new oncology drugs.” The pipeline drugs are “expected to be increasingly narrowly focused as precision medicine and biomarker-driven therapies become even more common. Notes: Oncology includes therapeutics and not supportive care.” Dedicate time now to review your vendor partners, ensure expertise in the natural flow of precertification/prior authorization enabling a second opinion without additional lift, and create sourcing partnerships with designated healthcare systems to pay fair market price.
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