FINANCIALTOXICITY
Yousuf Zafar, MD, MHSAssociate Professor of Medicine and Public PolicyDirector, Center for Applied Cancer Health Policy
Duke-Margolis Center for Health PolicyDuke Cancer Institute
OF CANCER CARE
THE
Mariotto et al, JNCI 2011
HOW MUCH DOES CANCER COST?
0
20
40
60
80
100
120
140
160
180
200
2010 2020
$ Bi
llion
Used with permission
Why?
$100
$1000
$10,000
$100,000
$10
Bach P,http://www.mskcc.org/research/health-policy-outcomes/cost-drugs
$11970 1980 1990 2000 2010 2017
BIOLOGICS2003
IMS Institute 2014
IMS Institute 2014
BIOLOGICS2013
Photo: TV advertisement, BMS
$10,000 a month
Gordon et al, JCO 2017
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
Why?
0%
50%
100%
150%
200%
250%
300%
1999 2002 2005 2008 2011 2014 2017Kaiser Employer Health Benefits Survey, 2017
Inflation
Worker earnings
47%
64%
0%
50%
100%
150%
200%
250%
300%
1999 2002 2005 2008 2011 2014 2017Kaiser Employer Health Benefits Survey, 2017
Inflation
Worker earnings
Premiums224%
47%
64%
0%
50%
100%
150%
200%
250%
300%
1999 2002 2005 2008 2011 2014 2017Kaiser Employer Health Benefits Survey, 2017
Inflation
Worker earnings
Premiums
Worker contribution to premiums 270%
224%
47%
64%
$-
$200
$400
$600
$800
$1,000
$1,200
$1,400
2006 2008 2010 2012 2014 2016Kaiser Employer Health Benefits Survey, 2017
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
$-
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
0 5 11 17 23 29 35 41 47
Milliman Report, 2017Months from diagnosis
Lung
ColorectalBreast
MONTHLY BANKRUPTCY RATES, WESTERN WASHINGTON STATE
Ramsey et al, Health Affairs 2013
MONTHLY BANKRUPTCY RATES, WESTERN WASHINGTON STATE
Ramsey et al, Health Affairs 2013
2.65xRISK OFBANKRUPTCY
MONTHLY BANKRUPTCY RATES, WESTERN WASHINGTON STATE
Ramsey et al, JCO 2015
7,570
79%HR 1.79 (1.64, 1.96)
matched patients
greater mortality risk
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
Upper 75th percentile >$53/monthaRR, 1.70; 95% CI, 1.30 to 2.22
Zullig et al, J Onc Pract 2013
45%WERENON-ADHERENT
n=254
Extreme financial distress
Greater risk of
mortality
Well-being
Health-related quality of life
Quality of care
?
Financial distress
Non-adherence
Missed appointmentsBankruptcy
Taking fewer medications
Selling property
Spending savings
Delaying care
Declining tests
Buying less foodBuying 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 appointmentsBankruptcy
Taking fewer medications
Selling property
Spending savings
Delaying care
Declining tests
Buying less foodBuying 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
OUTCOMES-BASED PRICING
Months
Patients with
disease response
1
79%
12
46%
Prasad V, Nature 2017
Kymriah - $475,000
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.
$46,868
$7350
16%US Census, 2015
HHS Notice of Benefit and Payment Parameters for 2018
MANUFACTURERS
GOVERNMENT
INSURERS
HEALTH SYSTEMS
MANUFACTURERS
GOVERNMENT
INSURERS
HEALTH SYSTEMS
Highvalue
Lowvalue
Chernew M et al, Health Affairs 2007
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
Basch et al, JAMA 2017
n=766
5 month improvement in overall survivalHR 0.83 (95%CI 0.70-.99)
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
No difficultieswith cost
Want thebest care
My doctorcan’t help
Talked tosomeone else
Not mydoctor’s job
Embarrassed
43%
28%
18%
18%
9%
9%
Zafar et al, AJMC, 2015
Why didn’t you discuss costs?
n=299
Proportion with lower costs after cost discussion
57%Zafar et al, AJMC, 2015
reported lower costs due to a cost discussionwith their oncologist
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
TALK ABOUT COSTS
KNOWLEDGEBASE
FINANCIAL NAVIGATION
COMMUNITY
Used with permission