I want to highlight a paper from the Journal of Clinical Oncology Practice by Cole et al##.
The research team looks at three drugs that have similar survival benefits for Chronic Myeloid Leukemia (CML). One drug, imatinib is now generic while the other two drugs are still brand name, patent protected drugs. The outcomes the researchers looked at were ER visits, inpatient hospitalizations and annual health care costs.
included 1,417 receiving imatinib, 1,067 receiving dasatinib, and 647 receiving nilotinib. The 1-year risk of safety events was… higher risks among patients receiving dasatinib (RR, 1.17; 95% CI, 1.06 to 1.30) and nilotinib (RR, 1.07; 95% CI, 0.93 to 1.23) compared with those receiving imatinib. Over a median of 1.7 years, the cumulative incidence of safety events was higher among patients receiving dasatinib (HR, 1.23; 95% CI, 1.10 to 1.38) and nilotinib (HR, 1.08; 95% CI, 0.95 to 1.24) than among those receiving imatinib. One-year health care expenditures were high (median, $125,987) and were significantly higher among patients initiating second-generation TKIs compared with those receiving imatinib (difference in medians: dasatinib v imatinib, $22,393; 95% CI, $17,068 to $27,718; nilotinib v imatinib, $19,463; 95% CI, $14,689 to $24,236).
CONCLUSION:Patients receiving imatinib had the lowest risk of hospitalization or emergency department visits and 1-year health care expenditures.
So what does all of this mean?
The first take-away is that treating CML is expensive no matter what drug is chosen. Insurance design fails when one treatment option could have an annual price of $115,000 while the other choice has a total annual cost of $140,000. Deductibles are being met in the first few weeks of treatment no matter what choice is being made. Coinsurance shuts off as maximum out of pocket limits are hit fairly quickly. Our regular tools to shift people to high value care instead of low value care are grossly ineffective at these price levels.
Secondly, imatinib leads to fewer side effects and it is cheaper than the other two drugs. It ties the other two drugs on survival and beats the other two drugs on side effects and cost. It dominates. Yet, only 45% of the treated population get the drug that is at least as good and significantly cheaper than the alternatives.
This is a case where alternative payment models for care can be very effective in shifting physician behaviors. If a CML diagnosis triggers a bundle that is designed to be big enough to readily pay for average cost of care for imatinib plus a little bit more, two things will happen. First, some physicians will change their prescribing behavior towards imantibib and away from the brand name drugs. That could make the market slightly more valuable for other generic makers to enter and drop prices significantly. Secondly, the average price of the brand name drugs will decrease to hold onto marketshare.
CML seems to be an area where there is significant volume, significant controllable price variation and meaningful clinical near substitutes. Those attributes makes CML an attractive alternative payment method target.