Tag Archives: Cancerscape 2017

Drug Pricing in the Crosshairs

by Amanda Patton, ACCC Communications

Drug pricing reform is in the news again this week as the Medicare Payment Advisory Commission (MedPAC) voted unanimously April 6 in support of the Commission’s multi-part Part B recommendations that include a Drug Value Program (DVP) with elements that align with President Trump’s interest in requiring drug companies to bid for government business.

ACCC17-Cancerscape“Despite Trump’s outreach to industry leaders and declaration of support for reducing drug prices, any attempt at price reform will be hard fought,” Jessica Turgon, MBA, ECG Management Consultants, told attendees last week at the ACCC 43rd Annual Meeting, CANCERSCAPE. The “how” of executing drug pricing reform will be “impressive,” Turgon said. She outlined five possible reform scenarios for lowering U.S. drug costs. The unknown: which reforms will the Administration stick to the most?

  1. Importing cheaper drugs from other countries in an effort to reduce average domestic drug prices. Pro: This might force drug companies to lower prices domestically. Con: It could result in higher drug prices worldwide.
  1. Increasing availability of generic drugs by requiring the FDA to speed up the approval process for generic versions of drugs. There is a similar option being put forward to hamper or make illegal the practice of “pay to delay,” which slows generic drug advancement. In fact, one study found that “pay to delay” has cost U.S. consumers $14 billion by keeping brand name drugs as the sole source product when cheaper, generic versions were available.
  1. Allowing Medicare to negotiate for drug prices using its leverage as the largest healthcare payer to achieve lower drug prices. This would require legislation or possibly execution through the regulatory process. However, the Congressional Budget Office has indicated this option would not have that great of an impact on federal spending, Turgon said.
  1. Increasing the use of value-based drug purchasing, i.e., paying for drugs based on the outcomes they achieved (i.e., treatment effectiveness) and not on a flat fee or other standard pricing approach. If this were integrated into protocols or pathways, it’s not clear how the financial results would be quantified, Turgon noted. However, as last year’s proposed Medicare Part B experiment showed, the impact would be very hard on providers.
  1. Scaling back the scope of the 340B Drug Pricing Program, for example, by revising the definition of a covered entity. The program remains in MedPAC’s crosshairs, Turgon warned. In FY 2013, covered entities saved $3.8 billion on outpatient drugs through the program; the number of 340B covered entity sites grew to 16,500 in 2013, a rise of nearly 8,000 sites from 2008. Turgon’s take-home message for cancer programs: Ask yourselves, “If I had to operate without my 340B program what would my cancer program, hospital, or health system look like?” Would it would likely have a significant impact on your health system overall? Is 340B funding “everything else” [e.g., services that are currently not-reimbursed, such as patient navigation] at your hospital right now?

Add to the mix, MedPAC’s recommendations for reducing spending in Medicare Part B. (Spending has gone up 9% every year since 2009, Turgon noted, which is not sustainable.) Briefly put, MedPAC’s recommendations fall into two track recommendations:

Track 1: Improve the average sales price (ASP) system.

  • Require drug makers to report ASP data and increase penalties for non-compliance.
  • Reduce WAC (wholesale acquisition cost), cut the add-on payment from 6 percent to 3 percent.
  • Require drug makers to give Medicare a rebate when the ASP price for a product exceeds an inflation benchmark.
  • Require the Centers for Medicare & Medicaid Services (CMS) to implement a common billing code for a reference biologic and its biosimilars.

Track 2: Establish a Drug Value Program

For this voluntary program, Medicare would contract with private vendors to negotiate prices for Part B drugs using tools like a formulary. The Drug Value Program vendor would negotiate directly with drug manufacturers. Providers would purchase all DVP products at the price negotiated by their DVP vendor. Medicare would reimburse providers for the DVP-negotiated price AND reimburse DVPs an administrative fee with a shared savings opportunity.

What Cancer Programs Can Do Now

What seems certain is President’s Trump continued interest in drug pricing reform. How (or if) reform is executed remains to be seen. MedPAC serves in an advisory role to Congress on Medicare issues—and whether Congress will consider MedPAC’s recommended changes to Part B is also uncertain. In the face of the many uncertainties surrounding drug pricing reform, cancer programs can still take proactive steps to address the rising cost of drugs, Turgon said. To do so, she suggested that cancer programs:

  • Develop and adhere to clinical pathways and protocols.
  • Determine the availability of evidence-based alternatives that are cheaper and comparable to high-priced drugs, and remove the higher-priced drugs from your formulary or tighten guidelines around use.
  • Deploy clinical pharmacists to educate prescribers about high drug prices.
  • Hold cost-of-care conversations with patients.
  • Reduce waste associated with high-cost drugs.
  • Keep negotiating with GPOs and wholesalers.
  • Identify signs of increases in drug prices as close to real-time as possible to avoid delays in taking action to minimize financial impact.
  • Keep the lowest possible inventory of high-cost drugs.
  • Keep communication lines open with senior administrators so they stay informed of the impact on the drug budget.

Final takeway: “Run your hospital-based cancer program as a private practice and know where your costs are,” Turgon advised.

Next Steps for Value Frameworks?

by Amanda Patton, ACCC Communications

ACCC17-Value Framework Panel (2)The mantra of “moving from volume to value” is ubiquitous in healthcare today.  So what do cancer programs need to know about evolving value frameworks in oncology? Attendees at the ACCC 43rd Annual Meeting, CANCERSCAPE, in Washington, D.C., heard real-time updates on two of the leading frameworks—ASCO’s work-in-progress Value Framework  and NCCN’s Evidence Blocks™.

Both value frameworks aim to be tools used in support of patient―physician shared decision-making according to panelists Stephen Grubbs, MD, FASCO, Vice President of Clinical Affairs, American Society of Clinical Oncology, and Robert Carlson, MD, CEO, National Comprehensive Cancer Network.

ASCO’s Value Framework was not built on drug pricing, but to have a discussion with a patient on potential financial toxicity and the benefit of the treatment in the context of how much the treatment will cost the patient, explained Dr. Grubbs. ASCO’s framework uses three primary parameters to calculate value: clinical benefit, toxicities of treatment, and cost. “Our goal at ASCO is to develop a tool that could be customized with information for each individual patient,” said Dr. Grubbs.

After receiving more than 400 comments on its original Value Framework draft, ASCO published a revised version in May 2016.  Grubbs made clear, however, that ASCO’s framework is still a work in progress. “It’s not yet ready for use,” he stressed.

In 2017 ASCO is working on improving the framework methodology, Dr. Grubbs explained, noting that a current weakness is that the framework is set up to compare a randomized clinical trial between two different treatments.  “If I have a treatment where I use drug A versus drug B, and than I have a trial that compares drug B to drug C—how do I compare drug A to drug C?” Work is underway at ASCO to address cross-trial comparisons and also to “anchor the net health benefit score in some meaningful way,” Grubbs shared. Finally, ASCO will continue work with patient advocates and patients to identify endpoints that are meaningful for patients.

On the other hand, NCCN’s Evidence Blocks are operationalized. NCCN’s goal was to create a “flexible value system that could be used to develop each patient’s equation for what is valuable,” said Robert Carlson, MD, CEO, National Comprehensive Cancer Network. NCCN Evidence Blocks are built on five metrics:

  • Effectiveness (efficacy)
  • Safety (adverse events, toxicities)
  • Data quality
  • Data consistency
  • Affordability

The Evidence Blocks are presented in a graphic format so that a user can look for “30 different options in about 4 or 5 seconds and come up with regimens that would be optimal for a specific circumstance,” Dr. Carlson said.

Like ASCO, NCCN intends the Evidence Blocks to support a patient-centered approach to integrating a value discussion into everyday practice. “We look at Evidence Blocks as a conversation starter, not an answer,” Carlson said.  “We don’t tell the patient, because the Evidence Block looks like this, this is what you should do. It’s a question of what’s most important to them.”

Currently, 33 of the NCCN guidelines have Evidence Blocks associated with them. By the end of 2018 all of the NCCN guidelines that have systemic therapies should have Evidence Blocks, according to Carlson. NCCN also intends to expand the Evidence Blocks into other treatment modalities. “We are now starting to look at other modalities, radiation oncology, surgical oncology, and diagnostics . . . in terms of the same sort of scales,” he said.

Rounding out the discussion, panelist Ali McBride, PharmD, MS, BCPS, The University of Arizona Cancer Center added perspective on the cost/value discussion as it may unfold on the frontlines of care. “Many patients may not be able to afford the 20% copay cost for IV therapy, let alone the out of pocket cost for many oral therapies,” he said. “We have to spend a lot of time detailing out those costs for patients, and if they can’t afford it, we have to say, then what’s our next step in that guideline pathway?”

All three panelists noted the need for financial transparency for patients and providers as one component of the value discussion.

In closing, panel moderator Christian Downs, JD, MHA, Executive Director, ACCC, asked panelists to consider what the value framework discussion might look like 10 years down the road.

Acknowledging the difficulty of making any predictions about the future shape of the oncology value discussion, Dr. Carlson envisions technology playing a pivotal role. “My own expectation and hope is that within a decade we will have computer-based systems that patients are able to interact with directly and help define and discover their own value system,” he said. Such a system would enable patients to indicate if they were more concerned with neurotoxicity or cardiotoxicity, for example. Plus the system would also have the capacity to query payers so that patients could know the financial impact of their therapy.

Big data (if the promise is realized) may change the face of value frameworks, noted Dr. Grubbs.  The potential of extensive real-world databases will bring “much more information on what happens to patients outside the narrow clinical trial that has the best, the most robust patients. . . [and extend to] what happens in the real-world. . . . if we had a big data system that had all this information about what happened to everybody and you could really home in on what happens to a 75-year-old person who was not in the clinical trial and have the cost data, you might come up with a very different looking value [framework] from what we’re showing you here today.”

Finally, as value frameworks continue to evolve, community cancer programs and practices have an important role to play, panelists agreed.  “There’s a huge reservoir of expertise and experience in community oncology, and we’d love to tap that, to learn from that. [One of the] ways you can help us, is to continually give us feedback in terms of whether we have it right or wrong. . . . talk to us,” Dr. Carlson said.

Dr. Grubbs concurred, adding that community oncologists are key to making value frameworks functional. “When you see this come out, please make comments back to ASCO on how to make this better, because nobody is going to get this right…right from the beginning.”

CANCERSCAPE Kicks Off with Perspectives on Policy and Business

by Amanda Patton, ACCC Communications

Last week’s events on Capitol Hill provided a dramatic backdrop for the ACCC 43rd Annual Meeting, CANCERSCAPE, March 29-31, bringing together hundreds of oncology professionals from around the country for insights, strategies, and perspective in the midst of healthcare reform ambiguities.

Cancerscape 2017-keynote panelIn a keynote session Thursday morning, policy insiders Kavita Patel, MD, MS, of The Brookings Institution, and Dan Todd, JD, Todd Strategy, LLC, shared insights on possible next steps toward Affordable Care Act (ACA) repeal or repair under the Trump Administration. ACCC Health Policy Director Leah Ralph moderated the point-counterpoint discussion covering what went wrong with the House Republicans’ American Health Care Act (AHCA) legislative effort at ACA repeal, mounting political pressures on Capitol Hill, legislative or administrative options to effect ACA repair, flaws in the design of the faltering individual insurance exchanges and what may (or may not) happen next, and whether the Administration will act on the hot button issue of drug pricing.

Cancerscape 2017 keynote panel 2Asked for one final takeaway that attendees should bring back to their programs to help their colleagues understand the policy landscape, Dr. Patel shared this perspective for frontline clinicians and administrators:

“No matter who is the party in power there’s always going to be this emphasis on cost. I don’t see the pressure to decrease costs going away. It may come in the form of programs like MIPS and commercial programs like ACOs and patient-centered medical homes, but as a physician who is in all of those programs, it’s all about having me [as a physician] understand where I’m over utilizing care . . . . If there’s one takeaway . . . it’s not to sit . . . and wait to see how things shake out.” Start looking for where you have unwarranted variation, where you can start implementing programs that actually matter to patients, Dr. Patel advised. “Take back some introspective ability to look at your variation, look at your costs, look at all the things that fall into P & L for administrators and how do you translate that to where clinical care is delivered.”

Dan Todd left attendees with one final advocacy takeaway: “It’s a new Administration with training wheels still on. . . they’ll ultimately get their balance. . . . If you have priorities, educate your congressional members on [them]. . . your voice is really, really important.”

For more, read OncLive’s coverage of the session here.

Conway-The Advisory BoardThe morning’s second session shifted the focus outside the Beltway to explore emerging cancer care delivery trends and potential impact on the business of providing cancer care. Lindsay Conway, MSEd, of The Advisory Board, briefed attendees on The State of Today’s Cancer Programs, highlighting five key trends shaping the delivery and business cancer care delivery:

  • Healthcare reimbursement and reform is at a pivotal point. Uncertainty continues around the future of the ACA and the insurance exchanges.
  • Increasing numbers of cancer patients with comorbidities requiring enhanced care coordination. From 2000 to 2010, the number of Medicare patients with multiple chronic conditions grew 22%. Proactive steps in care coordination for this population include regular distress screening to identify issues early and devising and implementing care maps for navigators.
  • Telehealth technology bringing care to patients where they are. These technologies and emerging patient-centered tools—ranging from real-time virtual visits, to phone apps, to patient portals, to remote patient monitoring—have tremendous capacity for expanding patient access to care
  • Growth of healthcare consumerism requiring cost and quality information. There are growing online resources for healthcare review, cost and quality information. To address consumerism in cancer care, it’s important for cancer programs to provide information to help patients select the right provider and the right services.
  • Genomic medicine is transforming cancer care. With the rapid pace of change in this area, cancer programs are challenged to invest carefully as they move forward to integrate precision medicine into practice.

More coverage on this session is available here.  To learn more about the ACCC 43rd Annual Meeting, CANCERSCAPE,  visit us at accc-cancer.org.

A Strong Voice in Challenging Times

By Amanda Patton, ACCC Communications

ACCC Capitol Hill Day 2017On Capitol Hill yesterday, in nearly 100 meetings with legislators and staff, ACCC advocates spoke out sharing the real-world impact of policy on cancer patients and cancer care delivery in communities across the country. Walking the halls of Congress were ACCC member physicians, nurses, administrators, pharmacists, social workers, financial advocates, and other members of the care team—from cancer programs and practices large and small—representing 23 states.ACCC Capitol Hill Day 2017

In conversations with legislators ACCC advocates urged that Congress:

  • Protect patient access to care, encompassing access to comprehensive affordable insurance coverage
  • Maintain meaningful access to clinical trials
  • Reject the NIH funding cuts proposed in the President’s FY 2018 budget and instead increase funding for NIH and the National Cancer Institute that is critical to our federal research infrastructure
  • Support federal oral parity legislation

Rep. Higgins-ACCC 2017 Hill DayDuring a lunch address, Congressman Brian Higgins (D-NY), who co-sponsors the Cancer Drug Parity Act of 2017 (H.R. 1409) told ACCC members, “Your constituents are our constituents,” and “your presence here [on Capitol Hill] is very important.”

In these challenging times, as Congress continues to deliberate reforms to our healthcare system, ACCC advocates spoke with a united, strong voice, encouraging their legislators to set aside politics and put patients first. Summing up the experience, Hill Day participant ACCC President Jennie R. Crews, MD, MMM, FACP, said, “Being on Capitol Hill today, it’s apparent that health reform is not dead and we need to remain vigilant that protections are there for our patients.”


ACCC Capitol Hill Day kicks off the ACCC 43rd Annual Meeting, CANCERSCAPE. Follow the meeting conversation on Twitter using #CANCERSCAPE as we live-tweet top takeaways. Stay tuned for blog updates with meeting highlights.

Why I’m Going to Capitol Hill On March 29

By Virginia Vaitones, MSW, OSW-C

U.S. CapitolACCC Capitol Hill Day 2017 happens to coincide with national Social Work Month, which the National Association of Social Workers is marking with theme Social Workers Stand Up.  As an oncology social worker, this year I’m putting on my patient advocate’s hat, standing up, and going to Capitol Hill to share with legislators the stories of how my patients are being impacting by worry and uncertainty about how  changes to the Affordable Care Act and the Medicaid program may affect their insurance coverage and access  to care.

My home state of Maine has the distinction of having the oldest population in the country per capita and Knox County, where I live and work, has the oldest population in the state.  Many of my patients who are on Medicare also have MaineCare (Maine’s Medicaid program) as their secondary insurance.  The current proposed changes to how the federal government supports states with Medicaid funding will have a tremendous impact on my patients.

Besides the elderly population that I need to advocate for, the proposed cuts and changes in payment will have an impact on my younger patients who become disabled with their cancer diagnosis and depend on Medicaid to cover the cost of their cancer treatments.  As a patient advocate, I will be standing up for these patients as well.

My advocacy skills also are needed to bring the stories of how cancer impacts parents, small business owners, and working adults with a cancer diagnosis, who for the first time were able to afford health insurance under the ACA and now face uncertainty about whether they will have coverage or be able to continue to afford the cost of coverage.

Last but not least, I work in a rural community hospital whose doors are always open and that will treat patients whether or not they have insurance coverage.  I need to advocate for my hospital so that we can keep our doors open.

Capitol Hill Day, March 29, will bring together ACCC members representing cancer programs from across the country.  Together we will be standing up for our patients, for access to quality care close to home, and for our cancer programs.


Virginia Vaitones, MSW, OSW-C, is oncology social worker at Pen Bay Medical Center in Rockport, Maine, and a past president of the Association of Community Cancer Centers (ACCC).