Le rapport prix/valeur des médicaments d’oncologie à l’épreuve des méthodes de paiement aux États-Unis

Price and Value for Oncology Drugs in the United States are Influenced by the Methods of Payment for Physician Services: A Game of Chess between Insurers, Physicians, and Hospitals

In France, oncology is largely a hospital-based service, and oncology drugs have long been reimbursed through the hospital-based case rate system (GHS), supplemented with payment for especially high-cost and innovative drugs and devices (“liste en sus”). In contrast, oncology in the United States largely is conducted in the ambulatory setting, and does not fall under the hospital case rate system (DRG) in that nation. Reimbursement for infused cancer drugs traditionally has been made directly to the prescribing physician, who purchases the drugs from pharmaceutical distributors and administers them to the patient in his or her personal office, referred to as payment by “buy and bill”. This payment method has been subject to considerable criticism for creating undesirable incentives for over-prescription, and has been modified in recent years by Medicare and private insurers. The “buy and bill” margin for oncologists has been reduced through mandatory limitations (Medicare) and negotiated limitations (private insurers). Paradoxically, however, this margin reduction has created the undesired effect (from the perspective of the insurers) of driving the practice of oncology increasingly from the ambulatory setting into clinics owned by hospitals. This has led to an increase in prices to the insurers, since hospitals are able to negotiate higher rates of drug reimbursement from insurers than are private physicians. These higher prices result in higher margins, which again creates an incentive for over-prescription, this time on the part of the hospital-based oncology clinics and employed oncologists. Insurers are now responding to this new dilemma by switching away from “buy and bill” reimbursement altogether, rather than merely seeking to reduce “buy and bill” profit margins. There is a push in the U.S. to link payment to documented appropriate patterns of use, interpreted as use within evidence-based clinical pathways. In France, there is a distinct but in some ways parallel debate over how to measure and reward the value created by oncology drugs as they are used in the real world and not merely in controlled research settings. The aim is to pay for clinical outcomes based on a new generation of performance agreements between purchasers and producers. This debate takes place under huge financial constrain that goes far beyond traditional agreements on appropriate use (“contrats de bon usage”) for expensive biologics.