As we told you in this recent post, a limited number of payers believe one way to better manage the current cancer drug spend is via cancer pathways, essentially a “soft formulary” approach that attempts to standardize care based on publicly available evidence tied to a therapy’s efficacy, toxicity, and cost.
Calling 2012 “an inflection point” for cancer pathways, Dr. Ira Klein, national medical director for Oncology Strategy at Aetna, believes “payers have a responsibility in pushing forward with these programs.” Since that responsibility doesn’t extend to choosing the care regimens that will ultimately be “on pathway”, it’s hardly surprising that a cottage industry of clinical pathway providers has sprung up in recent years to help physicians select the optimal treatment course for their patients.
Traction in the marketplace doesn’t just depend on payer adoption. Pathway “technology has to be easy to use and able to capture data quickly,” or physicians – especially community based oncologists — won’t adopt it, notes Klein. He believes the software is evolving rapidly and that better tools mean “there will be more transparency about what costs what and where the savings are.”
For now, three pathway providers –US Oncology’s Innovent Oncology subsidiary, Cardinal Healthcare’s P4 Healthcare, and D3 Oncology Solutions’ Via Oncology — dominate the marketplace. They have also captured the lion’s share of payer alliances thus far. A small upstart named eviti hopes to change this. It is betting its software, which offers “transparent” outcomes and cost data for more than 120 cancers in a web-based format, provides advantages that competing products can’t yet match. On January 26, eviti presented its business model at CMS’ Care Innovations Summit.
The road to adoption hasn’t been straight or swift. Capitalized by Patrick Soon-Shiong, the former CEO of Abraxis Bioscience and part-owner of the LA Lakers, privately-held eviti is a decade-old and only recently hit upon its business model of selling oncology decision support tools. One big distinction it tries to make between itself and its rivals is its objectivity: its competitors, it says, are also involved in the distribution of actual drugs or have direct relationships with providers. In contrast, eviti desires to be a strict service vendor that provides information to both payers and providers. In other words, says Dr. Arlene Forastiere, eviti’s SVP of Medical Affairs, the company has “no financial interest in the treatment decisions” made by physicians or reimbursed by insurers.
Included in eviti’s software are cost data based on average wholesale price for more than 1100 different oncology regimens. The pitch to physicians is three-fold: in an era when physicians are time-pressed yet measured by the quality of care they deliver and potentially on the hook financially if costs are mismanaged, a tool that delineates the standard therapies and their costs and helps ensure reimbursement ought to be of interest. According to eviti, early data suggest the technology reduces non-compliant care from around 32% to as little as 9%.
Meanwhile, for physicians worried about getting paid back for their drug purchases, eviti claims it has a solution. If a physician chooses a specific regimen that’s in compliance with current best practices, the treatment plan also receives an eviti code that’s akin to a prior authorization. “In real time, the practice has an authorization based on the patient’s diagnosis that is tied to the literature,” says eviti business development head Susan Spaulding. That’s in contrast to the current system, where a physician’s office can spend three or four days of back-and-forth on the phone with the payer before a treatment regimen is approved.
For the eviti code to work as planned, payers have to agree to cover any regimen as long as it’s “on pathway”. Right now that’s not an issue; payers like Aetna are actively avoiding mandating the use of specific pathways over others, even though data may suggest a cheaper therapy is equivalent to a more expensive one.
Nor is it likely payers will opt to use eviti’s cost data to push particular therapies. In the first place, drug costs are only part of total therapy costs — and a more expensive drug might reduce other costs by a larger amount. More importantly, choosing regimens by cost is politically untenable.
Still, payers’ acceptance of eviti codes might drive physician adoption of the software. Even if the outcome is simply shifting the cost decision to the treating physician, some health policy experts believe pricing transparency at the point of care will result in the greater utilization of less costly therapies. As Peter Bach, a physician and health policy expert at Memorial Sloan-Kettering Cancer Center and a former advisor to CMS noted in an IN VIVO article last year, “if there is no downside associated with a cheaper regimen, why wouldn’t the doctor use it?”
We’ll have more to say on the potential impact cancer pathways may have on drug companies in a future post.
Image by flickrer morten gade via creative commons.