How to approach value in oncology

Because cancer is often seen as “life or death” it is difficult for a payer to make decisions on how much a therapy is “worth,” according to a new study published in the Journal of Managed Care & Specialty Pharmacy. 

Schafer“Value in oncology is a growing discussion trend in the managed care and healthcare communities,” says Jeremy Schafer, senior vice president, director of payer access solutions at Precision for Value. “In order to assess value however, payers need independent analyses and guidance from expert bodies on how value in oncology can be approached.”

Precision for Value surveyed 28 health plan representatives from 27 unique organizations representing 160 million covered lives; 17 of the 28 were medical directors and 11 of the 28 were pharmacy directors. After 28 had responded, the survey was closed.  A follow-up one-hour interview was done with six individual respondents who had attested to using two or more value frameworks in their drug management processes. The goal of the interviews was to understand what each respondent liked or disliked about each framework and what they would like to see included in a value framework designed for payers.

The survey found that 71% of respondents (20 of 28) used at least one oncology value framework to inform their drug management; 29% of respondents used two frameworks; and 14% or respondents used three frameworks.

 National Comprehensive Care Network (NCCN) Evidence boxes were the most commonly used value frameworks with the Drug Abacus being the least used. Respondents liked that NCCN Evidence Blocks were regularly updated and easy to use but did not like the lack of quantifiable cost guidance. ICER reviews were popular for being scientific and providing a calculated “value price” that payers could use but were also seen as complex and not being updated. The American Society of Clinical Oncology (ASCO) framework was praised for having the capability to compare older therapies to newer ones but was criticized for lacking drug comparisons outside those that did not have a head to head trial.

Value frameworks

Payers felt the most important need for value frameworks was regular updating, preferably quarterly, according to the survey. Frameworks that are not regularly updated lose relevance as the clinical and usage picture of a drug changes, according to Schafer.

“Payers also wanted to see frameworks that gave ‘firm’ recommendations meaning that a value price should be calculated and that the framework should provide guidance on what the therapy was really worth,” he says.

Payers also like the idea of including patient-reported outcomes and quality-of-life information since these may matter in palliative care and end-of-life disease, according to the survey. Finally, payers believed web access for frameworks was optimal as that was easy to access and use.

Next: A fast-moving field

“Oncology is a fast-moving field and the arrival of value frameworks marked the first time payers in the U.S. had credible tools to assess oncology drug value,” Schafer says. “Knowing that payers would be interested in these frameworks, we wanted to understand how payers are using them and also understand payer perceptions into the strengths and weaknesses of each framework.

"In addition, since none of the frameworks were specifically designed to inform coverage decisions, we wanted to understand what payers would like to see if there was a ‘payer-centric” value framework designed in the future,” he says.

The value frameworks provide some guidance on assessing the value of oncology therapies and are being supported in some cases by leaders in oncology like NCCN and ASCO, says Schafer.

“Payers appear to be increasingly using these frameworks as part of their decision-making process," he says. "However, payers also seem aware of some of the shortcomings of each framework. It is important for managed care execs to understand the positives and negatives of these frameworks so that coverage decisions are not made based on erroneous assumptions.”

In addition, the frameworks may be useful guidance to health systems and integrated delivery networks, according to Schafer. “With the Oncology Care Model (OCM) there is a growing push to consider cost in oncology management. Health systems and payers participating in the OCM are thus incentivized to pick the highest-value therapies. The value frameworks may offer some insights on that.”