In February, President Biden announced the reboot of the Cancer Moonshot and vowed to reduce cancer mortality by 50 percent in the next 25 years. It’s a goal that’s both lofty and achievable — but only if the advances in science are accompanied by progress in controlling costs and innovations in financing cancer treatment.
Research and public health advances over the last three decades have already reduced cancer mortality by about one-third. Vaccines can now prevent many cases of cervical, head and neck, and liver cancer. Breast cancer can be detected early with currently available screening tests and cure and survival rates increase every year. Lung cancer and metastatic melanoma, which were once a death sentence, can often now be effectively treated for years or decades with these newer therapies. Ninety percent of those with childhood leukemias are cured, and patients with one type of adult leukemia have near-normal life expectancy.
But these miraculous advances in treatment have come with skyrocketing costs. For example, the intravenous immunotherapy medicine to treat metastatic melanoma costs almost $200,000 per year. In 2009, the lowest launch price for a cancer drug in the United States was less than $6,000 per month; in 2019, it was more than $15,000 a month. Average annual cost of cancer drugs approved from 2015 to 2020 was $196,000, and some patients require more than a single drug.
As a result, many cannot afford the optimal treatment for cancer. Those with cancer diagnoses were 71% more likely than similar people without cancer to have an adverse financial event such as a mortgage in default, bills sent to collection agencies or overdue credit cards. Among those with medical debt, people with cancer were more likely to have skipped or delayed medical care, declared bankruptcy, or lost their home compared with those without cancer. Further, the cost of oncology treatment has driven increases in health care premiums. Oncology drugs already make up almost half of the total prescription costs.
All of this shows that medical advances will be most effective if they’re widely available and affordable. But it’s been a month since the relaunch, and we know little about what the Biden administration is doing to be sure the innovations from the moonshot are affordable. And that certainly won’t happen if the moonshot team is made up entirely of cancer researchers.
It’s crucial that the moonshot include economists and health care finance experts who can determine how to pay for upcoming advances in cancer care. The most exciting new advances will save lives only if patients have access to treatment. Yet the initial Cancer Moonshot included 10 “transformative research recommendations,” none of which were related to how to finance newly-improved care. Big new advances often require out-of-the-box thinking about financing. Cancer researchers are appropriately focused on advancing diagnostics and therapeutics, not designing new financial arrangements.
Here are six approaches economists and health care finance experts might consider to drive adoption of Cancer Moonshot innovations.
1. Require research grants to include post-marketing access and affordability in contract language
The National Institutes of Health is the largest funder of basic research and often holds critical patents for innovations. The nation can learn from the experience of Operation Warp Speed and require that novel therapies based on government-funded research be affordable after they are marketed. This can include contracts that prevent exorbitant prices for treatments that are developed from research funded by the moonshot.
2. Design a federal reinsurance to fund care for those who will benefit from expensive treatment
Flood insurance is often unavailable to those living in low-lying communities, and the federal government has addressed this need through subsidies and risk-sharing. Cancers with expensive drug therapy are similarly hard to insure through conventional employer-sponsored health insurance, where a single member’s expensive treatment could threaten the viability of a small- or medium-sized business. A national reinsurance pool to finance and administer drug acquisition for those who could benefit from new medications could make care affordable to those with these severe diseases, maintain stability of our current insurance system, and guarantee cash flow to pharmaceutical companies for their innovations.
3. Create subscription programs
The cost of drug development is high, but the cost of production is usually low once a drug is approved. High prices currently maximize pharmaceutical profits, but many who would benefit from expensive therapies are unable to obtain them. Profit could be maintained with lower prices if more people used the medication. One model here is Louisiana’s subscription arrangement for hepatitis C therapy, which expanded access to life-saving treatment to all those who might benefit from new innovations while providing a regular cash flow to the pharmaceutical company. This model quintupled those on Medicaid eligible for treatment in one academic medical center, and almost all those treated were cured.
4. Reconsider the ban on the Food and Drug Administration considering cost during the approval process
The U.S. is the only major developed country that does not allow its drug regulatory agency to consider pricing when it evaluates a new drug for approval. Other countries extract pricing concessions in conjunction with initial approval. We can develop a comprehensive accounting of the societal cost of this legislative prohibition and propose alternatives that will maintain incentives for innovation while providing affordable access to innovative new drugs.
5. Promote and measure health equity in cancer treatments
The Cancer Moonshot can help us address the large racial disparities in cancer diagnosis, treatment, and outcomes. We can require research trials to include diverse subjects, so innovations are available most widely. Financing of care delivery for innovations from the Cancer Moonshot should be equitable and inclusive, so these benefits can be shared by all. We should also prospectively develop a measurement strategy so that we can assess the interrelationship of cancer treatments and health equity.
6. Evaluate warranties for expensive new therapies
Some pharmaceutical companies now offer guarantees or warranties, promising to refund costs if patients get no benefit. We need research to ascertain under what circumstances such financing mechanisms will increase access and affordability, and to issue guidelines about reconciliation processes. Warranties are likely to be less important if we pool purchasing or reinsurance, and are only of value if vigorously enforced.
The possibilities of Cancer Moonshot and advances in oncology care are thrilling and deserve our full support. But the full benefit of the Cancer Moonshot depends on keeping prices sustainable and providing financing options to allow widespread adoption of newly developed advances to combat this deadly disease.
Jeff Levin-Scherz, M.D., MBA, is a managing director and population health leader of the North American Health and Benefits practice at WTW. He is an assistant professor at the Harvard T.H. Chan School of Public Health.
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