Q&A with Jennifer Malin, MD: Putting Cancer Care on the Right Path

In the era of the $10,000-a-month drug, clinical pathways are the best hope for reining in costs and getting patients the care they need, says the vice president for clinical strategies at Anthem.

Interview by Robert Calandra

Why did you choose cancer as a specialty? Was there a personal connection?

It was a combination of factors. I decided to become an oncologist when I was in my second year of training in residency in internal medicine. It really came down to having very personal relationships with my patients. At UCLA, where I did my training, we spent a lot of our time taking care of patients with cancer in the hospital.

Jennifer Malin, MD

Jennifer Malin, MD

Around the same time, my mom and two of my close female friends that were my mom’s age were diagnosed with breast cancer. I saw people near and dear to me dealing with a diagnosis of cancer. In those days, the system was not very patient-centered. I remember the way one of the women, Susan, was told that she had cancer. The surgeon walked by her laying on a gurney and said, “It’s cancer.”

There’s something very special about a doctor-patient relationship in any specialty. But as an oncologist, you really are privileged to walk at someone’s side as they’re going through this incredibly difficult journey in their lives. It’s a very special place to be. I still volunteer at the VA twice a month.

Could the people close to you afford the drugs they needed?

Back then, the drugs were all pretty cheap. Cost was not really an issue. It was more sort of the slash-and-burn mentality in oncology back then. There was no real attention to patient experience or symptoms. You were just supposed to deal with it. We didn’t have any of the good antiemetics that we have now. You could tell which patients were getting chemo. They were the ones with the big buckets sitting in front of their rooms. It was just this horrible, horrible experience.

So my initial attraction to oncology was how can we pay attention to the people going through this rather than just attacking the cancer? There were not great drugs, only about a half dozen of them.

What is success when you think about cancer treatment?

Throughout my career, I have been working toward a system in which someone diagnosed with cancer has a way to figure out whom to go to for care. Who is the most convenient clinician in their community who will provide quality care — the right care that’s affordable, and they aren’t paying for things that they don’t need but getting everything they do need?

I still get phone calls anytime anyone close to me is diagnosed with cancer. The first question is always: Where do I go for care? Where should I get treated? It’s very, very challenging in our current environment to figure that out. Our Cancer Care Quality Program is the first step along the path to providing our members with that kind of information, so they know that when they go to an Anthem provider, they’re getting quality care that is not going to break their bank.

The Cancer Care Quality Program — that is your clinical pathways effort. Is the rollout complete?

We just completed the rollout across all our regions. We started in our Midwest states and Georgia last July [2014]. Virginia just went live. It’s taken a little over a year to fully launch the program.

Have any results surprised you, financial or otherwise?

Most treatment lasts six to nine months. We don’t even have financial data on people from the first month that’s really robust enough to look at. We’re anxiously awaiting the results. Any time you roll out something new, there’s a lot of apprehension. But for the most part, the feedback we’re getting from practices is very positive. Now we’re excited to see what the results are going to be and how we can use this platform to both measure the program and improve the quality of care.

How many physicians and hospitals are involved?

We don’t have exact numbers, but probably around 3,000 to 4,000 providers have registered.

How do pathways differ from guidelines?

Guidelines are very, very broad and don’t really tell your doctor how to tailor the treatment. National Comprehensive Cancer Network [NCCN] guidelines, which are used the most by oncologists in this country, pick out patients that don’t have the mutations that would make them candidates for a couple of the new, targeted drugs. For example, for patients with the most common subtype of lung cancer and without specific mutations, there are 64 different treatment regimens that would be appropriate. Those 64 different treatment options have pretty similar outcomes. Their toxicity profiles are very similar. The survival is approximately a year, give or take. If you look at a few head-to-head studies, one may do a little bit better for certain patients by a magnitude of several weeks. But the outcomes are very similar. The costs vary tremendously, from about $450 for three months of treatment, to $65,000 for three months of treatment.

If your drug is the same as another drug in a regimen and it doesn’t provide an advantage in efficacy or toxicity but you price it higher, it won’t make it on the pathways.

Pathways tries to identify the two, three, five treatments that will be the most effective — the most cost-effective with the best side-effect profiles for about 80% to 90% of the patients. There’s still going to be nuances where a physician is going to sit down with a patient and think about regimen number 63 in the NCCN guidelines. But for most people with this subtype of lung cancer, there are about eight treatments that are usually the most effective. So, pathways really take it from 64 down to 8. You can still use any one of the 64, but the pathways really narrow it to the most effective, the best side-effect profiles, and the most cost effective for most patients. For other lung cancer subtypes, there are other pathways. Across all lung cancer subtypes, there are 23 Anthem pathways.

Can an oncologist choose a treatment outside those pathways and be reimbursed?

You will still be able to bill for your patient visits and all your treatment. Nothing changes from the way you practiced medicine before the program. We provide additional reimbursement for treatment planning and care coordination when the regimen is on pathway. They wouldn’t be eligible for the additional reimbursement, but they still are reimbursed for everything that they’re doing.

But the purpose is to influence treatment decisions, isn’t it?

Most of an oncologist’s reimbursement today comes from the profit margin on the drugs. If you think about a typical cancer treatment being, say, $5,000 a month, an oncologist is going to make $350 or more just on those drugs. There are different sources of revenue coming to them. They get rebates from manufacturers.

The additional reimbursement for selecting a pathway is just one revenue source to basically support the most effective and cost-effective treatment.

How do you explain pathways and what seems to be standardizing care to the public when we are hearing so much about the era of personalized cancer treatment tailored to people’s genomes?

Pathways are very much personalized. There’s a specific pathway for lung cancer for patients with an EGFR mutation. There’s a pathway for patients that have the ALK mutation. There’s a pathway for patients with lung cancer and no mutation. There are pathways for second-line treatment and third-line treatment.

Will pathways help bring the costs of drugs under control?

If you read what people have written about drug pricing, it appears that each new drug, even if it’s a me-too drug and doesn’t do anything innovative, is priced higher than the last drug. If a market was functioning appropriately, a me-too drug would come in at a lower price. So as a health plan, what systems can we put in place to help normalize that situation? Pathways are one way to do that. If your drug is the same as another drug in a regimen and it doesn’t provide an advantage in efficacy or toxicity but you price it higher, it won’t make it on the pathways. To get on a pathway, drugs that are really, truly, equally effective have to be more cost-effective.

Are other insurers inquiring about Anthem’s pathways model?

Insurance companies can’t discuss with each other exactly how they do different things. There has been a very vibrant, robust discussion among the various oncology providers, and the leading payers in the country. ASCO helps facilitate those conversations. A number of my counterparts and payers attend the same meetings that I do. We kind of share our different views and ways of thinking in these public forums. Most of the other large payers do have pathway programs in place. What’s unique about our program is we put it out to scale. I think most of the other programs are either regional or pilots and aren’t across their entire network.

Will pathways bring better efficacy and cost control to cancer treatment?

I think it will bring more value to cancer treatment. The challenge today is that cancer therapies are $10,000 — and sometimes $15,000 — a month. Occasionally, those therapies have made huge differences in patient lives. Gleevec really has changed how we treat chronic myelogenous leukemia. We used to treat CML patients with bone marrow transplants, and 40% would die during the transplant. After the bone marrow transplant, patients would live with horrible side effects from graft-versus-host disease. Now, they take a pill and seem to live out their natural life expectancy, with some side effects, but they are modest compared with the treatment we had before.

But very few new cancer treatments really cure people. Most $10,000- to $15,000-a-month treatments prolong people’s lives by a couple of months. Is a therapy that costs $50,000 to $100,000 to prolong someone’s life by a couple of months and still have horrible side effects, truly innovative and making a difference for people with cancer? What benefits are people truly getting? Let’s ensure that they get the treatments that are really the most effective and the most cost effective. If you don’t need a new $60,000 drug to do the same thing that a drug that’s been around for 20 years, then let’s not pay more. Let’s recognize and encourage practices to use the tried-and-true therapy. But if a new therapy really does make a huge difference, we want our members to have access to it and that doctors are rewarded for using them.

What is next for pathways?

Getting the data and analytics from the first year of the program and starting to understand what’s been happening and improvements we can make. Then we need to get the data into the hands of the providers so they can see what their performance looks like on pathways and other measures of quality, like ER utilization and hospitalizations.

A little bit longer term is getting data into a format that can be used for our members when they are making decisions about where to go for care.

What do you anticipate to learn from the data?

Prior to Anthem, I was doing outcomes research for about 15 years. I’ve learned never to have any expectations.

What do you want Anthem’s customers to understand about what the company is doing?

First of all, the Cancer Care Quality Program provides an infrastructure for us to communicate with all of our stakeholders about quality and value. We can communicate and recognize providers and practices for quality and value, but also help our other stakeholders, clients, and members see what quality and value looks like and use that in their own ways.

The second thing is that pathways are one tool but not the only tool. They’re one very important tool for helping our members, providers, and pharma partners understand what is going to drive improved outcomes in cancer care.