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Reimbursement of Oncolytics

Peter L. Salgo, MD; Noa Biran, MD; Carl T. Henningson, MD; Steven L. D'Amato, RPh, BSPharm; and Arturo Loaiza-Bonilla, MD, MSEd, FACP, explore the different factors affecting reimbursement of oncolytics, including the cost versus benefit.
Published Online: Mar 12,2018

Peter L. Salgo, MD: One of the comments you hear from people who really haven’t looked at this in detail is “Well, how much is a human life worth? Is 1 day of your life worth something to you?”

Noa Biran, MD: It’s not for us to say. It’s hard to sit in front of a patient who’s doing well—whose performance status is good—and they want more treatment. It’s hard to say, “I’m not going to give you this treatment.” When you’re sitting in front of somebody, it’s a very difficult thing to do. You want to help your patient. You want to give them the longest life possible. You don’t know if that patient is going to get 1 month out of that treatment or be on the other end of the curve and get a year out of that treatment.

Peter L. Salgo, MD: Statistically, as a group, 1 month is expected, 5 years is not.

Noa Biran, MD: Correct.

Peter L. Salgo, MD: But, you can’t do that on a 1-by-1 basis, can you?

Noa Biran, MD: No, you can’t.

Peter L. Salgo, MD: This is tough.

Carl T. Henningson, MD: It is being done in other countries. They negotiate with the pharmaceutical companies, and they’ll say, “We’ll pay such and such for this drug” and “We won’t approve this drug because it’s not good enough.”

Noa Biran, MD: Yes. Or “You can only give 1 good drug at a time.” In other countries, you can’t get carfilzomib with lenalidomide with dexamethasone. You can get 1 or the other.

Peter L. Salgo, MD: Who are the best negotiators here? Are the drug pricing organizations really good at negotiating, or are the specialty pharmacies who are set up to deal with the pharmaceutical companies better at negotiating? Who’s better at handling all of these issues? Is it the specialty pharmacy or the provider? Anybody want to jump in on this?

Steven L. D’Amato, RPh, BSPharm: There are a lot of pieces to that. If you look at specialty pharmacies and the pharmacy benefit managers (PBMs) in general, what do they do? They pick the most expensive drugs in their plans. That’s how they make their money. So, it’s not in the PBM’s best interest to use lower-cost drugs in their patient population; rather, it’s to use higher-cost drugs. That’s why you’re seeing the cost of care go through the roof with oral oncolytics. It’s not going the other way. So, I don’t know who the best negotiators are. I don’t know if that’s really the job of the federal government—to be negotiating prices for Medicare. Certainly, that’s not part of current legislation. That would certainly be a huge change for the government—to be able to negotiate prices. But, to your point, it does happen in Europe. The government says, “We’re going to pay X for it. Otherwise, we’re not using it.”

Arturo Loaiza-Bonilla, MD, MSEd, FACP: Yes. Now, the concern is that even when we’re trying to discuss the Affordable Care Act, there was the discussion of, which drug should we approve—or not—and who makes the decision? In the United Kingdom, it’s the NICE [National Institute for Health and Care Excellence] committee, which some people think is not nice. Who does it here?

Peter L. Salgo, MD: Unless somebody is going to evaluate the drugs and evaluate the cost of the drug versus the benefit of the drug, then it’s the Wild West out there, no?

Carl T. Henningson, MD: It is.

Steven L. D’Amato, RPh, BSPharm: It is.

Peter L. Salgo, MD: That’s interesting. Stay tuned, because this doesn’t have an answer in the immediate future.

Steven L. D’Amato, RPh, BSPharm: No. And to Noa’s point, it can’t continue. The bank will break. As all of these new agents come on board, and now with CAR [chimeric antigen receptor] T-cell therapies, you’re getting into the hundreds of thousands…

Arturo Loaiza-Bonilla, MD, MSEd, FACP: Half of a million dollars per...

Peter L. Salgo, MD: Stop—a half of a million dollars for what?

Noa Biran, MD: Per treatment.

Arturo Loaiza-Bonilla, MD, MSEd, FACP: For the whole treatment that the patient gets.

Noa Biran, MD: That’s not facility fee. That’s just the company drug fee.

Arturo Loaiza-Bonilla, MD, MSEd, FACP: It’s just the drug. It’s just Novartis delivering the cell that was actually apheresed in the office and sent back to them. Once it leaves the office, it becomes part of the…

Noa Biran, MD: But, they only get paid if it works.

Arturo Loaiza-Bonilla, MD, MSEd, FACP: Exactly. That’s the only thing. But, we know it works.

Noa Biran, MD: It works.

Peter L. Salgo, MD: A half of a million dollars. Is this per treatment? Per year? Per course of treatment?

Carl T. Henningson, MD: One treatment.

Peter L. Salgo, MD: How many treatments do you typically need?

Carl T. Henningson, MD: Just 1.

Noa Biran, MD: Hopefully, 1.

Steven L. D’Amato, RPh, BSPharm: Hopefully, 1.

Carl T. Henningson, MD: And, it’s not a cure.