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VAL UE IN CANCE R CARE : F I NDI NG T HE PAT H T O PROGRE SS Yousuf Zafar, MD, MHS, FASCO Associate Professor of Medicine, Public Policy, & Population Health Director of Healthcare Innoation Duke-Margolis Center for Health

  1. VAL UE IN CANCE R CARE : F I NDI NG T HE PAT H T O PROGRE SS Yousuf Zafar, MD, MHS, FASCO Associate Professor of Medicine, Public Policy, & Population Health Director of Healthcare Innoation Duke-Margolis Center for Health Policy Duke Cancer Institute

  2. Sha ttuc k L a b s E mployme nt (spouse ) AI M Spe c ia lty He a lth Advisory Boa rd Vivo r, L L C Sa mF und F a mily Re a c h F o unda tio n Boa rd of Dire c tors NI H Re se a rc h funding Astra Ze ne c a Co pe rnic us-WCG I RB Boa rd Me mbe r RT I Consulting Mc K e sso n

  10. Na ture , 2015 $13,000 a mo nth

  11. $11,000 $3232 $289 1980 2000 2016 P Ba c h. Me mo ria l Slo a n K e tte ring Drug Pric ing L a b

  12. Pric e of nivoluma b $13,200 $13,000 $12,800 $12,600 $12,400 $12,200 $12,000 2016 2017 2018 2019 ASP Drug Pric e s, CMS.g o v

  13. Go rdo n e t a l, JCO 2017

  14. 300% E mploye r c ontribution to pre miums 270 % 250% 200% 150% 100% 50% 0% 1999 2002 2005 2008 2011 2014 2017 K a ise r E mplo ye r He a lth Be ne fits Surve y, 2017

  15. $1,400 De duc tible s ha ve triple d $1,200 $1,000 $800 $600 $400 $200 $- 2006 2008 2010 2012 2014 2016 K a ise r E mplo ye r He a lth Be ne fits Surve y, 2017

  16. Ave ra g e c umula tive pa tie nt out- of- poc ke t c osts from time of dia g nosis $12,000 L ung $10,000 Colore c ta l $8,000 Br e a st $6,000 $4,000 $2,000 $- 0 5 11 17 23 29 35 41 47 Mo nths fro m dia g no sis Millima n Re po rt, 2017

  17. F o re g o ne va c a tio ns 68% Cut g ro c e ry e xpe nse s 46% De ple te d sa ving s 46% n=254 Za fa r e t a l, Onc o lo g ist 2013

  18. Hig h fina nc ia l burde n: Qua lity o f life a mo ng pa tie nts with a c tive c a nc e r a nd survivo rs adjusted beta 0.06 EQ-5D unit per financial burden category; p<.001 n=1000 Za fa r e t a l, JOP 2014

  19. % hig he r like liho o d o f no n-a dhe re nc e Uppe r 75th pe rc e ntile >$53/ mo nth a RR, 1.70; 95% CI , 1.30 to 2.22 Duse tzina e t a l, JCO 2013

  20. Buying less clothing Financial distress Buying less food Working longer hours Spread out chemotherapy Cutting out vacations appointments Missed appointments Bankruptcy Using credit Declining tests Spending savings Taking fewer medications Using other people’s medications Borrowing from friends or family Selling property Non-adherence Replaced prescriptions with over the counter medications Delaying care

  21. Buying less clothing Financial distress Buying less food Working longer hours Spread out chemotherapy Cutting out vacations appointments Missed appointments Bankruptcy Using credit Declining tests Spending savings Taking fewer medications Using other people’s medications Borrowing from friends or family Selling property Non-adherence Replaced prescriptions with over the counter medications Delaying care

  22. 2015 Za fa r SY, JNCI Pro vide r Pa tie nt Po lic y

  23. MANUF ACT URE RS GOVE RNME NT INSURE RS HE AL T H SYST E MS

  24. MANUF ACT URE RS GOVE RNME NT INSURE RS HE AL T H SYST E MS

  25. D S- BASE COME PRICING OUT

  26. MANUF ACT URE RS GOVE RNME NT INSURE RS HE AL T H SYST E MS

  28. I n o rde r to pro mo te c o mpe titio n… the Se c re ta ry [o f HHS]: 1. ma y no t inte rfe re with the ne g otia tions b e twe e n drug ma nufa c ture rs a nd pha rma c ie s a nd PDP spo nso rs; a nd 2. ma y no t re q uire a pa rtic ula r fo rmula ry o r institute a pric e struc ture fo r the re imb urse me nt o f c o ve re d pa rt D drug s.

  29. MANUF ACT URE RS GOVE RNME NT INSURE RS HE AL T H SYST E MS

  30. MANUF ACT URE RS GOVE RNME NT INSURE RS HE AL T H SYST E MS

  31. Hig h L o w va lue va lue Chernew M et al, Health Affairs 2007

  32. MANUF ACT URE RS GOVE RNME NT INSURE RS HE AL T H SYST E MS

  33. MANUF ACT URE RS GOVE RNME NT INSURE RS HE AL T H SYST E MS

  34. COST T RANSPARE NCY Pho to : Nic k Ve a se y, T IME , 2013

  35. % % o f o nc o lo g y sympto m-re la te d E D visits a re a voida ble Pa na tto ni e t a l, JOP 2018

  36. o f c a nc e r pa tie nts a dmitte d a fte r pre se nting to E D

  37. Bro o ks e t a l, He a lth Aff 2014 Ca nc e r c a re c osts 6 months from dia g nosis 16 % 48 % 100% 80% 60% 40% 20% 0%

  38. E xte nde d- hours urg e nt c a re Admissio ns ra te fro m E D Admissio ns ra te fro m urg e nt c a re Ade lso n K , Pe rso na l c o mmunic a tio n

  39. 2015 Za fa r SY, JNCI Pro vide r Pa tie nt Po lic y

  40. Re duc e fa tig ue fa tig ue Asse ss Pre ve nt fa tig ue

  41. Pre ve nt Asse ss Re duc e fina nc ia l fina nc ia l fina nc ia l to xic ity to xic ity to xic ity

  42. Pre ve nt Asse ss Re duc e fina nc ia l fina nc ia l fina nc ia l to xic ity to xic ity to xic ity

  43. inte rve ntio ns o c us o n F

  45. Do n’ t use c a nc e r-dire c te d the ra py fo r so lid tumo r pa tie nts with: • lo w pe rfo rma nc e sta tus (3 o r 4) • no b e ne fit fro m prio r e vide nc e - b a se d inte rve ntio ns • no t e lig ib le fo r a c linic a l tria l • no stro ng e vide nc e suppo rting the c linic a l va lue o f furthe r a nti-c a nc e r tre a tme nt. ASCO Cho o sing Wise ly

  46. Go a ls o f c a re

  47. Pre ve nt Asse ss Re duc e fina nc ia l fina nc ia l fina nc ia l to xic ity to xic ity to xic ity

  48. “Any re po rt o f the sta tus o f a pa tie nt's he a lth c o nditio n tha t c o me s dire c tly from the pa tie nt , witho ut inte rpre ta tio n o f the pa tie nt's re spo nse b y a c linic ia n o r a nyo ne e lse .” Na tio na l Qua lity F o rum

  51. 5 month improve me nt in ove ra ll surviva l HR 0.83 (95%CI 0.70-.99) n=766 Ba sc h e t a l, JAMA 2017

  52. Improve me nt in ove ra ll surviva l Pa tie nt-re po rte d o utc o me s Nivo luma b (SCCHN) Pe mb ro lizuma b (NSCL C) Ate zo lizuma b (NSCL C) Ca b o za ntinib (RCC) E rib ulin (lipo sa rc o ma ) 0 2 4 6 Ada pte d fro m K rzyza no wska , ASCO 2017

  53. Pre ve nt Asse ss Re duc e fina nc ia l fina nc ia l fina nc ia l to xic ity to xic ity to xic ity

  54. de sire a c o st disc ussio n % with o nc o lo g ists a c tua lly ha ve a % c o st disc ussio n n=299 Za fa r e t a l, AJMC, 2015

  55. Why didn’t you disc uss c osts? No diffic ultie s 43 % with c ost Wa nt the 28 % be st c a re Not my 18 % doc tor ’s job My doc tor 18 % c a n’t he lp T a lke d to 9 % some one e lse 9 % E mba rra sse d Za fa r e t a l, AJMC, 2015

  56. re porte d lowe r c osts % due to a c ost disc ussion with the ir onc olog ist n=299 Za fa r e t a l, AJMC, 2015

  57. How we r e c osts de c r e ase d? De c re a se d fre q ue nc y 6 % o f MD visits Cha ng e d te sts o r 13 % de c re a se d fre q ue nc y Switc he d to le ss 19 % e xpe nsive me ds MD a ppe a le d to 25 % insura nc e Re fe rre d to fina nc ia l 53 % a ssista nc e Za fa r e t a l, AJMC, 2015

  58. Me dic ar e Bad De bt $3.14 b illio n $3.69 b illio n 2012 2016 17 % inc r e a se T ra nsUnio n, 2018

  60. Pha se I - Re sults 30-pa tie nt fe a sib ility study 83% a g re e d/ stro ng ly a g re e d tha t Bridg e impro ve d kno wle dg e o f the fina nc ia l a spe c ts o f c a nc e r c a re 72% ma tc he d to a t le a st o ne fina nc ia l a ssista nc e pro g ra m Me a n o f 4 fina nc ia l a ssista nc e pro g ra m ma tc he s pe r pa tie nt T ra n e t a l, 2018

  61. T ria l Ca re c o o rdina tio n E HR’ s e nro llme nt Mo le c ula r E vide nc e dia g no stic s disse mina tio n Da ta Olde r, sic ke r stre a ms pa tie nts

  62. T ria l Ca re c o o rdina tio n E HR’ s e nro llme nt Mo le c ula r E vide nc e L e a rning dia g no stic s disse mina tio n He a lth Syste m Da ta Olde r, sic ke r stre a ms pa tie nts

  65. H

  67. Ana lyze da ta Cre a te Co lle c t kno wle dg e da ta Cha ng e pra c tic e

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