Kai Yeung

Asthma control, cost and race: results from a national survey

Abstract Objective: Although interventions have been shown to alleviate symptoms in most patients suffering from asthma, only one-third of asthma patients have disease that is well-controlled. The purpose of this study is to investigate whether partly and uncontrolled asthmas are associated with increased costs for asthma-related healthcare utilization compared to well-controlled asthma and to determine whether these associations differed across racial groups. Methods: We classified respondents from the Asthma Insights and Management survey into those with well-, partly and uncontrolled asthma and compared utilization of healthcare services and costs among these groups, as well as between whites and non-whites. Results: Respondents categorized as having asthma that was not well-controlled reported lower income levels, higher rates of unemployment and more trouble paying for healthcare; similar results were found in analyses stratified by race. Patients whose asthma was partly or uncontrolled had greater use of asthma-related medications and medical services compared to patients whose asthma was well-controlled. Total unadjusted and adjusted costs were greater in patients whose asthma was classified as partly and uncontrolled. Similar results were found in analyses stratified on race. Across all levels of asthma control, non-whites had higher rates of utilization of emergency rooms and urgent care facilities and had greater rates of hospitalizations compared to whites. Conclusions: Our findings indicate that patients with asthma that is not well-controlled utilized more healthcare resources and had greater medical costs, despite lacking of health insurance which may suggest less access to care.

Clinical and economic review of erlotinib in non-small-cell lung cancer.

Lung cancer has the highest incidence and mortality among cancers of both men and women. Treatment strategies for non-small-cell lung cancer, the most common form of lung cancer, continue to evolve, most recently with the positive trial results for EGF receptor (EGFR) tyrosine kinase inhibitors in the first-line setting in molecularly targeted populations. Despite these promising findings, EGFR tyrosine kinase inhibitors remain costly, and it is therefore important to assess the value of erlotinib therapy across the full spectrum of use. This is an up-to-date review of the clinical and economic impact of erlotinib for advanced non-small-cell lung cancer. Overall, the studies found that erlotinib, compared with available agents, provides slightly improved outcomes with variability in the incremental costs depending on the health system and patient characteristics. Additional studies are warranted exploring the cost–effectiveness of erlotinib as a first-line agent as well as the clinical and economic impact of EGFR mutation testing strategies versus usual care.

Using Performance-Based Risk-Sharing Arrangements to Address Uncertainty in Indication-Based Pricing

BACKGROUND The rise in pharmaceutical expenditures in recent years has increased health care payer interest in ensuring good value for the money. Indication-based pricing (IBP) sets separate, indication-specific prices paid to the manufacturer according to the expected efficacy of a drug in each of its indications. IBP allows payers to consistently pay for value across indications. While promising, a limitation of IBP as originally conceived is that efficacy estimates are typically based on clinical trial data, which may differ from real-world effectiveness. An outcomes guarantee is a type of performance-based risk-sharing arrangement that adjusts payments according to prospectively tracked outcomes. We suggest that an outcomes guarantee contract, which has been used by some payers, may be adapted to achieve indication-based prices supported by real-world effectiveness. OBJECTIVE To illustrate the potential of an outcomes guarantee to achieve indication-based prices aligned with real-world value, using a case study of trastuzumab for the treatment of metastatic breast and advanced gastric cancers. METHODS We estimated costs and outcomes under traditional IBP (i.e., expected value IBP) and outcomes guarantee frameworks and calculated incremental cost-effectiveness ratios (ICERs) comparing treatment with and without trastuzumab. Efficacy data came from pivotal trials, whereas effectiveness data came from observational studies. We adjusted trastuzumab prices in order to achieve target ICERs of

Authors’ Reply to Curto and Garattini: “Current Status and Trends in Performance-Based Risk-Sharing Arrangements Between Healthcare Payers and Medical Product Manufacturers”

150,000 per quality-adjusted life-year under each framework and for each indication. RESULTS To achieve the ICER target under traditional IBP, the unit price of trastuzumab using efficacy evidence was adjusted for metastatic breast and advanced gastric cancers from an average sales price of

Design, implementation, and first-year outcomes of a value-based drug formulary

9.17 per mg to

Current Status and Trends in Performance-Based Risk-Sharing Arrangements Between Healthcare Payers and Medical Product Manufacturers

3.50 per mg and

Price Elasticities of Pharmaceuticals in a Value-Based-Formulary Setting

0.93 per mg, respectively. Under an outcomes guarantee, the unit price of trastuzumab using effectiveness evidence was adjusted for metastatic breast cancer and advanced gastric cancer to

Paying for Cures: How Can We Afford It? Managed Care Pharmacy Stakeholder Perceptions of Policy Options to Address Affordability of Prescription Drugs

8.66 per mg and

Application Of Cost-Effectiveness Logic To Us Managed Care Drug Formularies: Long Term Outcomes Of A Value-Based Formulary

0.20 per mg, respectively. CONCLUSIONS Like expected value IBP, outcomes guarantee contracts can also vary payment based on indication. In addition, an outcomes guarantee can also reduce uncertainty regarding effectiveness and better align payment with the actual value of a treatment. DISCLOSURES No funding supported this study. Carlson reports consulting fees from Genentech, Pfizer, and Seattle Genetics. The other authors have no conflicts of interest to disclose. Study concept and design were contributed by Carlson, Yeung, and Li. Yeung, Carlson, and Li collected and analyzed the data. The manuscript was written primarily by Yeung, along with Carlson and Li, and revised by all the authors.

Using AHRQ's Evidence-Based Reports to Improve Managed Care Pharmacy Practice: Oral Antidiabetic Agents

We thank Dr. Garattini and Mr. Curto for their comments and will gladly provide further clarification [1]. The original article from which the taxonomy used in our current article was taken focused on health outcomes arrangements and excluded non-outcomes-based schemes [2, 3]. Therefore, the original article includes definitions for coverage with evidence development (CED), conditional treatment continuation (CTC), and performance-linked reimbursement (PLR) categories but not financial/utilization (FU). The FU category is represented by the non-outcomes schemes, which are included in the taxonomy figure, but not explicitly defined in the figure or in the text. We apologize if this caused some confusion. We define the FU category as arrangements where the reimbursement is tied to the measure of financial or utilization outcomes as opposed to explicit clinical outcomes. Subsequent to our original article and taxonomy publication, there have been both derivative and independently created taxonomies. One example—the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Task Force taxonomy—is similar to the original taxonomy, though it differs somewhat, as you have noted [4]. We did not choose to use the ISPOR Task Force taxonomy for our most recent work, opting to stay with our original. Regarding the CTC for Alzheimer’s drugs in Italy, the arrangement would not need to be officially listed as a management entry agreement (MEA) by AIFA, the Italian Medicines Agency, to be included in our review if it meets our criterion, i.e., continuation of coverage for individual patients is conditional upon meeting short-term treatment goals. Our information about this article came from a previously published news article [5]. To the extent this reference is accurate, the Alzheimer’s arrangement meets our criteria. Finally, we classified the arrangements in the UK and Italy according to the aforementioned taxonomy. The current paper provides the relevant numbers according to each of the taxonomic components. Most of the arrangements in Italy contained multiple components. For example, a common arrangement for a cancer therapy in Italy entails a treatment initiation period (often with a financial component with free product or a discounted price, i.e., an FU component), followed by evaluation of short-term response (CTC) with a refund for those not responding according to the predetermined response criteria (PLR). The UK has utilized multiple types of arrangements, but the last 25 Patient Access Schemes have been confidential discounts, suggesting a movement away from performance-based risk-sharing arrangements.