Value, Not Cost, Should Be Considered for Myeloma Treatment

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Many patients pay a copay for their MM medications, but this practice decreases value and does not incentivize the use of lower-cost drugs.
Many patients pay a copay for their MM medications, but this practice decreases value and does not incentivize the use of lower-cost drugs.

Survival of patients with multiple myeloma (MM) has dramatically increased during the past 15 years as the result of the approval of multiple novel agents. There is, however, concern that these novel therapies are associated with high costs that have profound negative financial effects for patients and society.

An article published in the 2018 American Society of Clinical Oncology (ASCO) Educational Book, based on an educational presentation at the 2018 ASCO Annual Meeting in June, highlighted that this view is not entirely accurate, particularly for patients with MM.1“The conversation needs to be centered around value, and not cost. Cost is only part of the equation that determines value,” Rafael Fonseca, MD, of the Mayo Clinic in Phoenix, Arizona, told Cancer Therapy Advisor.

Drug Prices and Bankruptcy

Drug prices are often blamed for the rising cost of health care, but drugs overall only contribute up to 20% of cancer care. Of total health care costs, cancer drugs only account for about 1% of the spend. 

Most patients pay a copay or coinsurance for their MM medications. Yet, economic analyses suggest that this practice decreases value and fails to incentivize the use of lower-cost drugs. As a result, to help patients afford drug costs, manufacturers offer copay assistance programs that act as a direct rebate. “The vast majority of patients with MM pay less than $100 per month in copays,” Dr Fonseca said.

Dr Fonseca noted, however, that “most of the medical literature that discusses problems with accessing medications is focused on Medicare patients, not on those with commercial insurance.” Medicare Part B (without supplementary insurance) and Part D require a 20% coinsurance payment of MM drugs, which can be substantial. Direct copay assistance from manufacturers through the use of copay cards is illegal for Medicare and Medicaid beneficiaries. In some cases, third-party foundations or organizations may provide copay assistance to these populations. 

Bankruptcy in patients with cancer is commonly attributed to high drug costs. Though a cancer diagnosis doubles the risk of bankruptcy, the net risk is low. Bankruptcy has also not been directly associated to drug copays. “People need to consider that there are many more factors that potentially could lead to bankruptcy, above and beyond that of simply paying copays for medications,” Dr. Fonseca said. Other costs include travel, hospital and doctor bills, and, for some patients, loss of income due to lost work days or an inability to continue working.

Value Versus Cost

The problem is not the conversation about health care costs, but the misrepresentation of the role of drug costs. “I think it is very important that clinicians work with formal economists in this conversation. We do not have the formal training to completely understand or develop the analysis that could best inform what to do,” Dr Fonseca said. 

Cost only partly contributes to value. According to Dr Fonseca, value means that “patients, society, and payers are getting a return economic benefit from the investment in paying for medications for the treatment of cancer.” Different measurements of value exist, such as cost per quality-adjusted life-year, but Dr Fonseca noted that many metrics fail to consider all aspects of value, including the value of life after a cancer diagnosis. 

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