Here’s a hypothetical question Roger Longman posed to a panel at the recent Real Endpoints Symposium that is probably worth a little thought from everyone; since the issues raised are intended to be general, I’ve modified this scenario slightly to try to make it as non-specific as possible, so it explicitly doesn’t (and isn’t intended to) apply to a particular disease state or to particular drugs.
Here’s his hypothetical:
Let’s say you are the CMO of a not-for-profit health plan, and are considering costs and reimbursement approaches associated with therapies for a disease that could be treated with Drug A or Drug B. The disease doesn’t cause any symptoms, but if untreated, serious organ damage could occur after many years. Drug A offers a 95% cure rate. Drug B offers a 88% cure rate. The manufacturer of drug B offers a very good economic deal to the payor, saying “If you place our drug first, we’ll offer you excellent pricing and also pay for patients who are failed by our drug to receive drug A.” What would you do?
The CMO in question, a physician, said he’d never been offered such a deal, but would seriously consider it. I asked him (somewhat self-righteously) how could he as a doctor, in good conscience, recommend a therapy he knew was inferior?
He responded that actually, this happens all the time – it’s what step therapy is (when you need to first try a lower-intensity treatment before receiving insurance authorization to get a higher-intensity treatment).
He also reminded the audience that he has a finite amount of money to spend, and if by spending less here, he’s able to provide more care to more people, then wouldn’t this make sense – especially if (as we’ve assumed) there was little harm done in receiving a trial of the slightly less effective drug first.
For good measure, he noted this happens all the time in most other countries – only in the U.S., does this approach seem strange.
Personally, I couldn’t imagine recommending Drug B to a patient in a world where Drug A existed; however, I also understand his arguments and his reasoning.
Perhaps this is an example of the conflict between a doctor who’s focused (appropriately, I’d contend – see here as well) on the health of her specific patient and a payor who’s focused (again, appropriately) on the health of a population.
Or perhaps, as some would contend, this is an example of the sort of problem that could be addressed if patients were on the hook for a greater fraction of the medication cost: as many have pointed out, we make decisions all the time whether to buy something fancy or something that’s just adequate. While everyone would prefer a 95% chance of immediate cure to a 88% chance if the cost was equal and minimal, what if it wasn’t? I suspect many patients would opt for a less expensive medicine that afforded an 88% cure rate if they were the ones directly paying for it. (To be clear: this is intended as an illustrative example only, not a proposal.)
So what do you think? What would you do if you were the payor here? The treating physician? The patient? Would your answer change if Drug B’s cure rate was 75%? 50%? What if the disease was associated with mild symptoms? Severe but not life-threatening symptoms? What if there was a higher chance that the untreated disease could suddenly get much worse?
David Shaywitz is co-founder of the Center for Assessment Technology and Continuous Health (CATCH) in Boston. He is a strategist at a biopharmaceutical company in South San Francisco. You can follow him at his personal website.