presented commentaries and strategies addressing the issues surrounding the high cost of cancer drugs.10-15
It was a groundbreaking 2012 letter to the New York
Times that brought the issue to public attention.16 Dr.
Peter Bach and his colleagues at Memorial Sloan Kettering Cancer Center announced they would not purchase a “phenomenally expensive new cancer drug”
for their patients, calling their decision a no-brainer.
The drug, ziv-afilbercept (Zaltrap), was twice the price
of a similar drug, bevacizumab (Avastin), but was no
more efficacious in the treatment of metastatic colorectal cancer. Bach and colleagues went on to say how
high drug prices are having a potentially devastating financial impact on patients and that laws protect drug
manufacturers to set drug prices at what they feel the
market will bear.
Considering the value of cancer treatments is now
actively encouraged. To that point, the American Society of Clinical Oncology (ASCO) has recently published
a groundbreaking paper entitled “A Conceptual Framework to Assess the Value of Cancer Treatment Options.”17
This tool, which is still in development, will allow oncologists to quantify clinical benefit, toxicity, and out-of-pocket drug costs so patients can compare treatment
options with cost as a consideration.
The financial burden put on patients has become the
driving force for drug cost reform. In an attempt to control their costs, third-party payers have increased the
cost burden for patients by demanding larger copays and
other out-of-pocket expenses for medications. It is felt
that requiring patients to have more “skin in the game”
would force them to make treatment decisions based on
cost. Unfortunately, this approach may lead to devastating financial consequences for patients.18-20 The overwhelming emotions patients experience following the
diagnosis of cancer make it difficult to focus on the financial impact of treatment recommendations. In addition, many oncologists are not comfortable, or even
capable, of discussing costs so patients can make financially informed treatment decisions.14 Unfortunately for
patients, “shopping for health care” has very little in
common with shopping for a car, television sets, or any
THE VA HEALTH CARE SYSTEM
The VA is government-sponsored health care and is
therefore unique in the U.S. health care environment.
The VA might be considered a form of “socialized med-
icine” that operates under a different economic model
than do private health care systems. The treatment of VA
patients for common diseases is based on nationally ac-
cepted evidence-based guidelines, which allow the best
care in a cost-effective manner. For the treatment of can-
cer, the use of expensive therapies must be made in the
context of the finite resources allocated for the treatment
of all veterans within the system.
The VA provides lifelong free or minimal cost health
care to eligible veterans. For veterans receiving care
within the VA, out-of-pocket expenses are considerably
less than for non-VA patients. Current medication copays
range from free to $9 per month for all medications, regardless of acquisition cost. This is in stark contrast to the
private sector, where patients must often pay large, percentage-based copays for oncology medications, which
can reach several thousand dollars per month. VA patients are not subject to percentage-based copays; therefore, they are not a financial stakeholder in the treatment
Prior to 1995, the VA was a much criticized and
poorly performing health care system that had experienced significant budget cuts, forcing many veterans to
lose their benefits and seek care outside the VA. Beginning in 1995 with the creation of PBM, a remarkable
transformation occurred that modernized and transformed the VA into a system that consistently outperforms the private sector in quality of care, patient safety,
and patient satisfaction while maintaining low overall
costs. The role of the VA PBM was to develop and maintain the National Drug Formulary, create clinical guidance documents, and manage drug costs and use.
Part 2 of this article will more closely examine the high
cost of cancer drugs. It will also discuss the role of VA PBM
and other VA efforts to control costs. ●
The author reports no actual or potential conflicts of interest
with regard to this article.
The opinions expressed herein are those of the author and do
not necessarily reflect those of Federal Practitioner,
Frontline Medical Communications Inc., the U.S. Government,
or any of its agencies. This article may discuss unlabeled
or investigational use of certain drugs. Please review the
complete prescribing information for specific drugs or drug
combinations—including indications, contraindications,
warnings, and adverse effects—before administering pharmacologic therapy to patients.