Autumn 2021

As cancer care expenses continue to skyrocket, new approaches to managing these costs require supportive resources for oncologists to navigate rapidly changing treatments.

The amount spent on cancer care in the U.S. represents a significant proportion of healthcare costs overall. Oncology and oncology support currently accounts for 61% of Medicare spend and 43% of Medicaid spend. Additionally, the cost for cancer drugs in the U.S. is projected to grow 105% from 2019-2024. This is in large part due to new and expensive drugs. Over the last five years, 25% of novel FDA drug approvals have been oncology related. In 2020, this percentage soared to 39%. As of 2019 there were over 700 drugs in clinical trial for oncology treatments. Though these innovative drugs for treating cancer may offer promising results such as improved effectiveness and reduced side effects, these new therapies often come with a hefty price tag and numerous indications to consider. 

Utilization of ICIs, a treatment that allows T-cells to kill cancer cells, highlights the expensive and complicated nature of these new therapies. ICIs experienced a growth in indications of nearly 600% between 2016 and 2020 with more than 120 cumulative indications. These treatments are mostly limited to stage 3 and 4 cancers further limited by indication. However, the “cutting edge” treatment bias can result in usage outside recommended guidelines, unnecessarily driving up costs. Managing these indications and employing appropriate usage is a challenge that would benefit from collaborative, peer-reviewed utilization management (UM) programs that work to identify effective care within National Comprehensive Cancer Network (NCCN) treatment guidelines. 

Utilization Management Support 

Utilization management (UM) offers confidence in appropriate, expedited treatment. 

There is a complicated indication route for ICI usage that relies on a battery of tests and associated results. UM promotes an accurate and timely review process for ICI treatment, lowering costs associated with off-label usage and ensuring patients are receiving appropriate care on a desirable timeline.

Spotlight: Regimen Comparisons

Cost Overview of ICI and Chemotherapy

Ensuring ICIs are being used within appropriate guidelines are of key importance for patient safety and overall cost of care. There are significant average monthly cost differentials across indication when comparing ICI and standard chemotherapy treatment regimens (see Figure 1). Based on NCCN guidelines and the recommended cadence of treatment for lung cancer, melanoma and colon cancer, ICIs may cost tens of thousands of dollars more than traditional chemotherapy.

Figure 1: Average Monthly Cost Across Indications for ICI and Chemotherapy Treatment
Source: Centers for Medicare and Medicaid Services. CMS 2021 ASP Drug Pricing Files. 

For further information, please contact:
Adam Goldston (email)
Chief Growth Officer
OPN Healthcare