Oncology prescribing has changed with the broad adoption of clinical pathways programs, bundled payment arrangements, and accountable care organizations (ACOs). Each of these managed care reforms is designed to promote cost-effective and evidence-based prescribing while working to lower costs of care, but each mechanism works differently to benefit or hamper specific oncology brands.

This report explores how these three managed care forces are reshaping the competitive pharmaceutical landscape for drugs treating colorectal cancer (CRC) and renal cell carcinoma (RCC) in different ways.

The landscape of agents for the treatment of CRC and RCC is changing, owing to the 2013 approval of capecitabine, the generic version of Roche’s oral Xeloda. The introduction of the generic version may attract oncologists to try it as single-agent therapy in stage III and IV CRC, potentially supplanting chemotherapy and chemotherapy with targeted agents (a crowded field including FOLFOX, CAPOX, and 5-FU/leucovorin in stage III, and Roche/Chugai’s Avastin (bevacisumab), Bristol-Myers Squibb/Eli Lilly/Merck/Serono’s Erbitux (cetuximab), Regeneron/Sanofi’s Zaltrap (ziv-aflibercept), and Amgen/Takeda’s Vectibix (panitumumab) in stage IV). The CRC market is poised for further change with the forecast 2016 launch of OncoVax, an immunotherapy for use as first-line therapy after surgery in stage II. To the extent that this agent succeeds in preventing recurrence, it will inhibit sales of all other agents for CRC.

In the RCC and CRC markets, prescribers’ choice of therapy and payers’ decisions about formulary inclusion and pathway placement will become increasingly complex as developers strive to differentiate new entrants within the evolving treatment algorithms and to position themselves as favorably as possible on payers’ formularies and on pathways.

In this report, we surveyed 100 oncologists and 40 managed care organization (MCO) pharmacy and medical directors to assess their attitudes, expectations, and reservations regarding pathways, bundled payment arrangements, and ACOs. We then pressed for detailed responses about how these managed care reforms are likely to influence access to, and prescribing of, specific agents.

Questions Answered in This Report:

  • Understand the extent of oncologists’ participation in clinical pathway programs, bundled payments and ACOs. What percentage of surveyed oncologists participate in pathways, bundled payments, or ACOs, or plan to do so within the year? What is the proportion of oncology patients covered under these arrangements? What cancers are included under the pathways and bundled payment arrangements? What services are covered in the payment bundles? What factors most influence choice of drugs for pathways? What are the concerns and problems involved in enacting pathways, and how can pharma companies influence those pathways?

  • Understand the extent of MCO participation in clinical pathways, bundled payments, and ACOs that include oncology services. What percentage of MCO oncology patients are covered under these arrangements? When MCOs design their own clinical pathway programs, how are they different from those originating with oncologists? What level of adherence to pathways is required for an oncologist to be considered compliant and therefore eligible for incentives?

  • Compare patients’ access under clinical pathways to various agents for treatment of CRC and RCC. What CRC agents are currently covered under clinical pathways for stage III and for various lines of treatment for stage IV? What proportion of oncologists’ patients receive each agent, either singly or in combination? What RCC treatments are currently “on-pathway” for various lines of treatment? How many patients under pathways have access to a third or fourth line of therapy? What are the pathway differences between the key subpopulations in CRC? How would oncologists prescribe for various stages and lines of treatment if they were not subject to pathways?

  • Assess patients’ access to drugs treating CRC and RCC under existing and planned bundled payment arrangements. What agents are typically covered under existing and planned bundled payment arrangements? What are the other care components covered under these bundles?

  • Explore likely impacts of capecitabine (generic Xeloda) and the planned launch of OncoVax in 2016. How are new pathways treating the new generic and what movement to the generic is anticipated by oncologists and MCOs? How soon after launch will pathways be amended to include Vaccinogen’s OncoVax? Will oncologists wait for the pathways to change before using it? What is the likely effect of having a generic oral therapeutic alternative in the mix with much more expensive oncology agents?

  • Examine the effect of ACOs’ guidelines and performance measures on oncologists’ prescribing. What measures do ACOs use to evaluate performance in the oncology setting, and how do those measures impact prescriber behaviors?

Scope:

This U.S. Physician & Payer Forum report contains insights from a survey of 100 oncologists and 40 MCO pharmacy/medical directors regarding clinical pathways, bundled payments, and ACOs and their impact on prescribing practices for the treatment of CRC and RCC in the United States. In this report, we explore the access to various agents in existing clinical pathways and bundles and in the pathways and bundle arrangements currently under development. We also explore how oncologists would wish to prescribe if they were unencumbered by these incentive-backed guidelines.

Markets covered: United States.

Primary research: Online survey of 100 neurologists and 40 MCO pharmacy or medical directors.

Author(s): Paula Wade

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