The Finances of Cancer Care: Patient Experiences and...

FINANCIAL TOXICITYOF CANCER CARE

Yousuf Zafar, MD, MHSAssociate Professor of Medicine and Public PolicyDuke Cancer Institute

THE

Used with permission

Mariotto et al, JNCI 2011

HOW MUCH DOES CANCER COST?

0

20

40

60

80

100

120

140

160

180

200

2010 2020

$ B

illio

n

2000 2010

$100

$1000

$10,000

$100,000

$10

Courtesy Peter Bachhttp://www.mskcc.org/research/health-policy-outcomes/cost-drugs

$1

1970 1980 1990

BIOLOGICS2003

IMS Institute 2014

IMS Institute 2014

BIOLOGICS2013

9

0

50

100

150

200

250

300

350

2007 2014

IMATINIB

400mg158%

ERLOTINIB

100mg91%

DASATINIB

50mg130%

$

Bloomberg News 2014

Mailankody and Prasad, JAMA Onc 2015

COST VERSUS BENEFIT

“Our results suggest that current pricing models are not rational but simply reflect what the market will bear.”

Mailankody and Prasad, JAMA Onc 2015

“ACCEPTABLE”

$50,000 - $200,000 per year of life in

perfect health

REGORAFENIB

1 year of life in perfect health:

$975,954Goldstein DA et al, JCO 2015

11%29%

40%

0%

50%

100%

150%

200%

250%

1999 2001 2003 2005 2007 2009 2011 2013

INSURANCE IS MORE EXPENSIVE

Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2013

Inflation

14%

34%50%

11%29%

40%

0%

50%

100%

150%

200%

250%

1999 2001 2003 2005 2007 2009 2011 2013

Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2013

Worker earnings

Inflation

INSURANCE IS MORE EXPENSIVE

57%

119%

182%

14%

34%50%

11%29%

40%

0%

50%

100%

150%

200%

250%

1999 2001 2003 2005 2007 2009 2011 2013

Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2013

Premiums

Worker earnings

Inflation

INSURANCE IS MORE EXPENSIVE

57%

119%

182%

56%

117%

196%

14%

34%50%

11%29%

40%

0%

50%

100%

150%

200%

250%

1999 2001 2003 2005 2007 2009 2011 2013

Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2013

Worker contribution

to premiums

Premiums

Worker earnings

Inflation

INSURANCE IS MORE EXPENSIVE

0%

3%4%

5%

7% 7%

11%

13%14% 14%

23%

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

FOUR-TIERED FORMULARIES

Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2013

Patient costs, 2014

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Orals IVs

$3,033

$7,040

IMS Institute, 2016

Ramsey et al, Health Affairs 2013

2.65xRISK OFBANKRUPTCY

7,570

79%

HR 1.79 (1.64, 1.96)

matched patients

greater mortality risk

Ramsey, et al, JCO 2015

Extreme

financial

distress

Greater

risk of

mortality?

Extreme

financial

distress

Greater

risk of

mortality

Well-being

46%

46%

68%Foregone vacations

Cut grocery expenses

Depleted savings

n=254

Zafar et al, Oncologist 2013

50%

39%

73%

willing to declare bankruptcy

willing to sell their home

willing to spend less on food/clothing

Chino F et al, in preparation

Extreme

financial

distress

Greater

risk of

mortality

Healthrelatedqualityof life

High financial burden:

Quality of lifeamong patients with active cancer and survivors

Zafar et al, JOP 2014

n=1000

adjusted beta 0.06 EQ-5D unit per financial burden category; p<.001

Extreme

financial

distress

Greater

risk of

mortality

Qualityof care

70%higher likelihood of non-adherence

Dusetzina et al, JCO 2013

Zullig et al, J Onc Pract 2013

45%WERENON-ADHERENT

Extreme

financial

distress

Greater

risk of

mortality

Well-being

Health-related quality of life

Quality of care

?

Financial distress

Non-adherence

Missed appointments

Bankruptcy

Taking fewer medications

Selling property

Spending savings

Delaying care

Declining tests

Buying less food

Buying less clothing

Using other people’s medications

Working longer hours

Cutting out vacations

Using credit

Borrowing from friends or family

Replaced prescriptions with over the counter medications

Spread out chemotherapy appointments

Financial distress

Non-adherence

Missed appointments

Bankruptcy

Taking fewer medications

Selling property

Spending savings

Delaying care

Declining tests

Buying less food

Buying less clothing

Using other people’s medications

Working longer hours

Cutting out vacations

Using credit

Borrowing from friends or family

Replaced prescriptions with over the counter medications

Spread out chemotherapy appointments

INTERVENE

Policy

Provider

Patient

Zafar SY, JNCI 2015

MANUFACTURERS

GOVERNMENT

INSURERS

HEALTH SYSTEMS

MANUFACTURERS

GOVERNMENT

INSURERS

HEALTH SYSTEMS

MANUFACTURERS

GOVERNMENT

INSURERS

HEALTH SYSTEMS

MANUFACTURERS

GOVERNMENT

INSURERS

HEALTH SYSTEMS

In order to promote competition…the Secretary [of HHS]: 1. may not interfere with the

negotiations between drug manufacturers and pharmacies and PDP sponsors; and

2. may not require a particular formulary or institute a price structure for the reimbursement of covered part D drugs.

MANUFACTURERS

GOVERNMENT

INSURERS

HEALTH SYSTEMS

MANUFACTURERS

GOVERNMENT

INSURERS

HEALTH SYSTEMS

Highvalue

Lowvalue

Chernew M et al, Health Affairs 2007

Imatinib for CML

Bevacizumab for pancreatic

cancer

Imatinib for CML

Bevacizumab for pancreatic

cancer

Imatinib for CML

Bevacizumab for pancreatic

cancer

MANUFACTURERS

GOVERNMENT

INSURERS

HEALTH SYSTEMS

MANUFACTURERS

GOVERNMENT

INSURERS

HEALTH SYSTEMS

Photo: Nick Veasey, TIME, 2013

PRICETRANSPARENCY

Policy

Provider

Patient

Zafar SY, JNCI 2015

Reducefatigue

Preventfatigue

Assessfatigue

Reducefinancialtoxicity

Preventfinancialtoxicity

Assessfinancialtoxicity

Reducefinancialtoxicity

Preventfinancialtoxicity

Assessfinancialtoxicity

high-value

Don’t use cancer-directed therapy for solid tumor patients with:

• low performance status (3 or 4)• no benefit from prior evidence-based

interventions• not eligible for a clinical trial• no strong evidence supporting the clinical

value of further anti-cancer treatment.

ASCO Choosing Wisely

Goals of care

Reducefinancialtoxicity

Preventfinancialtoxicity

Assessfinancialtoxicity

Nausea

Fatigue

Financial toxicity

Reducefinancialtoxicity

Preventfinancialtoxicity

Assessfinancialtoxicity

n=299

Do patients want to discuss costs?

52%

Zafar et al, AJMC, 2015

desire a cost discussion with oncologists

19% actually have a cost discussion

53%

25%

19%

13%

6%

How were costs decreased?

Zafar et al, AJMC, 2015

Referred to financial assistance

MD appealed to insurance

Switched to lessexpensive meds

Changed tests or decreased frequency

Decreased frequency of MD visits

Used with permission