Interesting editorial in the Journal of Clinical Oncology looking at the high costs of cancer care and raising the issue of health technology assessment programs (HTA) to evaluate cost/efficacy.
They note that HTA’s examine:
- Is the new treatment effective? Although surrogate end points such as response rate may be sufficient evidence of efficacy for regulatory agencies (eg, rise in hemoglobin after administration of erythropoietin stimulating agent), HTAs generally demand more direct evidence of benefit (eg, improved quality of life measured by a validated instrument, or improved survival).
- Which patients benefit? If the clinical trial population excluded particular patient populations, are they likely to have the same benefit as the patients included in the study?How does it compare to other available treatments?
- At what cost?
The editorial compares the costs in other countries and their rationale for paying for or not covering certain drugs.
“To calculate an ICER, one simply divides the average net cost of the treatment by the average net benefit in life expectancy (adjusted for the presumed quality of the increased longevity). For example, the increase in longevity of 0.33 months (6.2 months versus 5.9 months with gemcitibine alone) or 0.028 years associated with erlotinib in patients with pancreatic cancer at a net cost of approximately $11,500 would have an estimated ICER of $410,000/life years gained and $510,000/QALYs (if one discounts the life years gained by 20%, since those extra days in are in far from perfect health). A recent review of published cost-effectiveness analyses of cancer-related interventions (of which only half were pharmaceuticals) found that 8% were reported to be both cost saving and more effective (dominant) and 52% had an ICER of less than $50,000 per quality-adjusted life-year (QALY) gained, resulting in approximately 60% being below the ICER threshold used by NICE for determining their willingness to pay. The ICER was greater than $100,000 per QALY gained in 14% of interventions examined, and interventions were cost increasing and less effective in 11% of analyses. (Medicynical emphasis) Although cost effectiveness is not considered explicitly in the United States, an ICER of $100,000/QALY is often cited as a threshold for being reasonably cost effective.
The editorial references an article by Mason et al. comparing the approach in the U.S. and the U.K. It concludes:
Anticancer drug coverage decisions that consider cost effectiveness are associated with greater restrictions and slower time to coverage. However, this approach may represent an explicit alternative to rationing achieved through the use of patient copayments.
Medicynical Note: It’s apparent that we have reached the point where increased expenditures on health care at 2-3 time the inflation rate cannot be sustained. We actually reached this point 20 years ago but ignored it. Will we be able to do something constructive now? Or will our non-system move increasingly to rationing of care by copayments and the patient’s ability to pay.
Remember in our country the total savings of most people amount to less than the cost of one of these new targeted therapies.