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