Why Sanofi’s Zaltrap Deal Won’t Help Patients

A nurse prepares a patient for an infusion drug for cancer. Credit: National Cancer Institute.

I got excited when I read the New York Times story Nov. 9 (“Sanofi Halves Price of Cancer Drug Zaltrap After Sloan-Kettering Rejection)”. Zaltrap is an intravenous infusion drug for metastatic colorectal cancer. It is used for advanced cancer that is resistant to or has progressed with platinum-based chemotherapy. With a list price of  $11,000 per patient per month, Zaltrap is about double the cost of Genentech’s Avastin. Sloan-Kettering doctors rejected Zaltrap, claiming it offered no added value over Avastin, and it costs twice as much.

Doctors from Sloan-Kettering Cancer Center, one of the nation’s flagship cancer hospitals, didn’t do it quietly; they published an op-ed in the NYTimes Oct. 14, titled “In Cancer Care, Cost Matters.” They wrote:

“Soaring spending has presented the medical community with a new obligation. When choosing treatments for a patient, we have to consider the financial strains they may cause alongside the benefits they might deliver.”

The importance of getting bang for your buck, or value in healthcare, has been a huge sticking point in health policy circles in the United States. In fact, politicians of all stripes are quick to point to health outcomes data that show that despite the United States spending in the top tier of all nations for healthcare, health outcomes are far lower.

Unfortunately, the story in The Times Nov. 9 to Sloan-Kettering, could easily have been misread as a victory for affordability for patients. The headline states “Sanofi halves price…”. Sadly, the Zaltrap half-off deal is not a list price reduction at all. It is just a business discount plan for hospitals and oncologists. As Lisa Jaffe Hubbell, who uses high-cost disease modifying drugs for a noncancerous, chronic condition told me:

“It won’t help patients, will it? Our copay will be based on full price, the docs will pocket the extra from insurance companies. It doesn’t really help anyone who is in need of help paying for healthcare.”

Another woman with stage IV breast cancer explained to me that she has been deemed ineligible for any discount for her high-priced cancer drugs because she is insured. In general, drug discount plans go to the uninsured. She emailed me:

“The drug I took for five years was re-patented three times while I was on it, as I recall. It was orders of magnitude more expensive than the old standby tamoxifen for only a slight advantage in efficacy.”

As The Times points out, Medicare patients are unlikely to see a lower price for Zaltrap for a long while until the discount is incorporated into Medicare payment calculations for Part B, which covers physician-administered drugs. In addition, oncologists have long marked up drugs that they administer for insurers and patients.

Fortunately, Sloan-Kettering doctors are on the patients’ side and question whether Sanofi’s discount will make Zaltrap more affordable for patients. Peter Bach, MD, told me: “I don’t know if they’re going through steps to ensure reimbursement goes down to follow price or not. I’m hoping that is in their plans. If not, then yes, the windfall goes to providers, and our concern is the costs passed on to patients.” Leonard Saltz, MD, the op-ed coauthor, and gastroenterology oncologist, from Sloan Kettering also called Sanofi to task in the Nov. 9 NYT article for missing the boat in making Zaltrap affordable for patients.

But pharmaceutical price fixing is nothing new, according to Frederic Kaye, MD, professor of hematology and oncology at the University of Florida in Gainesville, Florida. “I saw this happen for the first time in the late 1980s when a veterinary pill levamisole, which cost pennies for the treatment of heartworm, underwent a 100 times price escalation when it was used for treating colon cancer. There was outrage at the time over lack of regulations for price fixing, but you see almost 25 years later, it is the same.”

Sanofi’s drug discount plan is clearly a business imperative. If one of the US flagship cancer treatment centers says that they will not use Zaltrap, others could follow. But the refusal to lower Zaltrap’s list price is worrisome because patient copays are based on price.

More importantly, if the Sanofi plan becomes the pharmaceutical industry’s MO in the era of value-based healthcare, patients will still gain no financial relief from the high cost of drugs. Value-based healthcare will be something for facilities and hospitals.

These days, you have to critically review the hoopla about “patient-centered health care” and the allegedly positive partnerships shaping healthcare. Were patients included when it really mattered in drafting this drug discount program? We need to maintain a high level of skepticism about deals made strictly between drug companies and hospitals, or arrangements made between industry and physicians, or industry and health plans. It’s been said before and it must be said again: “Nothing about me [the patient] that pertains to me should be done without me at the table.”

This story appeared first as a guest blog on Scientific American guest blogs, Nov. 19, 2012.


Mental Health for the 99% Following Hurricane Sandy

Two weeks after Hurricane Sandy and a Nor’Easter that left thousands of New Yorkers without light, heat, and power for weeks, many New Yorkers were understandably shaken. Some had endured 911 and the disruption, though of an entirely different cause, elicited an anniversary stress reaction. Deaths, drownings, and unacceptable losses happened here and in many other areas.

In New York, I tried assisting a friend get psychiatric help who was traumatized after 911. She feared that she’d sink into the morass that she did following 911.
Here’s the picture that emerged:

>Many psychiatrists in New York City take no insurance. For many people, this means 100% out of pocket, or possibly a small reimbursement.
>Trauma and post-traumatic stress disorder are not something primary care physicians (PCPs) want to deal with, nor is it appropriate for them. Let’s hope health plans don’t think it is within their purview.
>Many PCPs in New York City have no psychiatric referrals to offer patients that are in network.
>Many major academic medical centers in the 5 boroughs have no participating psychiatrists at all in the largest health plans in the area. How can that be?
>Listings of participating psychiatrists in health plan networks are enormously inaccurate: psychiatrists tell you that they have not been on these plans for years.
>One friend in need got two off-network psychiatrists to consult with: the first offered a first visit for two hours at $695, followed by repeat visits of $350.
>She reached that one after ten calls to psychiatrists off list.

I know that this is not unique to New York, nor is it unique to mental health. What do you think should be done to change this? Are there more equitable ways to be sure mental health services serve people most in need?