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Is the Inflation Reduction Act a Threat or Opportunity for Oncology?
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Released: December 06, 2024

Expiration: December 05, 2025

John Marshall
John Marshall, MD
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Maybe You Should Care About the Inflation Reduction Act- Your Job Might Depend on It…

[00:00:05]

John Marshall, MD: Hey everybody, John Marshall live from Washington D.C. where all the action is happening. A lot of moving vans are likely to be coming here soon as the new party comes in to take over maybe everything. We're going to have to see how that goes. We're all living in this crazy state of uncertainty about just how much of what they are they saying is going to happen. But we'll see. That's our future.

But what I really want to talk about on this episode of Oncology Unscripted is the beginnings of a discussion around health policy in oncology, and the reason I'm bringing this up is I just recently came across my radar, something called the Inflation Reduction Act. Well, sure, I knew about the Inflation Reduction Act, but I didn't know how that was going to affect cancer. And then I started to think about, yeah, I do. They're going to negotiate drug pricing on cancer. And there's been this big turmoil about we can't do that. It'll break the system. We need the fixed drug pricing, et cetera, and I want to talk about that because it's starting to be put into place, and it might actually get wiped off the map in a couple of months, but maybe it won't. And I wanted to talk about it because it will affect what I do for a living, and that's to try and develop new drugs for cancer.

But in order to do that, let's start by at the beginning of when the whole thing needed to be created in the first place. And that is go back to 2003 Bush II, Bush II to put into place a health modernization Medicare Modernization Act, which at the time was praised. Now, remember where we were people with Medicare didn't really have drug benefits. You went and paid cash at the pharmacy. But drugs were getting more and more expensive. And so, seniors weren't able to afford the drugs. And so, we needed to figure out how U.S. healthcare was going to cover those drugs. And this was the deal that was cut now out of that deal. So, seniors got access to drugs. But for the tradeoff that always happens here in Washington, D.C. Now, the first one was that there was an agreement that we would not import new drugs from other countries. So, in other words, you couldn't manufacture it in Canada and then ship it across the border at Canadian prices. We weren't going to allow that. So, the borders were closed to import so that we could save the price structure here in the United States. And with that rule came another corollary is that we could not negotiate drug pricing with the manufacturer. Whatever they said was going to cost, that's what CMS would pay. And as a result, that was when we could no longer judge value as a nation. So, if you can't connect magnitude of benefit, which is what the FDA judges, did it work or not, to the cost, that's what CMS has to do, you can't judge value. Right? There's no way. Okay, it'll cost $100,000. Okay, but what do I get for that? Well, it could only be 6 weeks. And that would be enough for it to get FDA approval. And Medicare would have to pay. the third component was something called 340B pricing, and that is institutions like mine and many of the institutions around the United States pay a reduced amount for the product, get paid by insurance companies, the delta, and with that extra money that we get as a healthcare institution, we're supposed to provide All those other things that cancer care delivers. A nutritionist, a social worker, nursing support, et cetera, that don't have any billing infrastructure for it.

And so that non negotiated price, the rising cost of cancer drugs, and this 340 B pricing is our current economy. And with that, all of our industries are more or less dependent on that pricing structure. So, the inflation reduction act is a threat to that, right? Because if we're going to start picking and choosing drugs that can be negotiated on price, then how does that affect the revenue stream? And how does that affect the reimbursement into research? So, our whole series on the next few episodes is going to be focused on the Inflation Reduction Act and what it does now, and what it could do in the future. And why we're worried about it. We hope to get some good folks who are in the middle of this discussion to talk to us about it. It's a fairly sensitive subject. So, we are hoping for that. So, stay tuned to future episodes.

Cancer Care in America: Equal Access or Uneven Outcomes?

[00:05:05] But as part of this episode, I wanted to talk about yes, U.S. health care, but I wanted to talk about. Does everyone get the same U.S. healthcare? Now, the reason this has become important to me is that we just did a study here in Washington, D.C. between two of our main hospitals that I work in. They service very different patient bases and neighborhoods. They're both busy cancer hospitals. They both provide specialized cancer care. That's important. But one, quote unquote, has a lot of issues with social determinants of health. Barriers to access to cancer care, because as we've talked about, cancer care is complicated to receive, it's complicated to give, and if both parties are doing okay, then it's okay, but if one is challenged, then it's not okay, right?

So, what we did is a big study of a thousand patients with colon cancer, and actually extracted from their charts, 400 from one hospital, 600 from another. And believe it or not, we were expecting to see a difference in outcomes that the social determinants of health were in fact going to affect the outcomes for those patients. But not only did we see no difference, we saw that. In fact, our record here in our health care system was better than published national averages. Molecular profiling, time to treatment, survival, all the key points we want. And after an initial sense of pride, I'm like, well, wait a second. That is not what we were expecting, right? We were expecting there to be a difference because of the populations that we were serving was different.

And so, we then developed a new theory, which we are testing now, that can a general oncologist, nobody out there get offended, keep up. With everything that needs to be kept up with in every disease, and I think if you ask most general oncologists, they would say they do a very good job, which I would agree with, but maybe not as good as it could be.

On the other hand, what if you live in a remote part of the world in our country? How far do you have to go to even find a cancer doctor or a place where you can get an infusion? So, we have this issue of general oncologists and remote access, right?

Bridging the Distance: Can Rural America Get Equal Access to Cancer Care?

And so there have been a couple of, you know, announcements lately about new projects. There was one that looks like it was funded by ASCO and it's in rural Montana where they're going to use a hub and spoke model where there's going to be infusion sites around and then they'll be in a remote part of the country, but then there'll be centralized care. It's exactly how Canada does it now, all the doctors live along the southern border of Canada, right? Because that's the only place there's not snow all the time. And they've talked to, using telemedicine, patients who live up further away. And then there are local nurses and general doctors who administer the cancer care. So that hub and spoke model we know works in the Canadian health care system.

There was recently Iowa, as you might imagine, great centralized cancer care, but how do they care for folks out and around? So, the University of Iowa bonded with Mission Cancer and Blood, 280 million dollars changed hands, but to basically deliver cancer care in a remote areas. Now this is great. This is what we need for our people and for everyone around our country is good access to cancer care.

But what our little study may be hinting at is maybe this also needs to be done by cancer specialists. Should we begin to divide even general practice knowledge into its subcategories because it's gotten so complicated? The analogy I like to use is if I had a bunch of okay. And the answer is no, I can be an expert in one or two, but I can't know all the nuances of all the different board games. So we're going to have to figure out not only provide cancer care for everybody, but Through these kinds of networks, hub and spoke model, but how do we make sure that we're actually delivering the highest level of cancer care that we can so that our patients can get the best outcomes and the best and the right therapies on time, et cetera.

Is the U.S. Health System Designed to Fail Its Patients?

So, the last point I want to make about all of this health care policy. It really comes from a recent survey paper that looked at the different health care systems and outcomes around the world. And we always think, because we're the United States of America, that we have the best of everything. Well, we do have the best hamburgers, that I'm going to give us. Maybe the best fried chicken, too. I would say that's probably true. Best bourbon? Yeah, I think we have that. But in terms of the best care and health care, when you look at the top, like richest countries, we don't. We're in fact, of the top ten, guess what number we are? We're the worst in terms of access to care. Bad health outcomes. Bad. Worse. So, 9th in administrative efficiency. I didn't need to tell you that equity. We're 9th in that where we are. The best is what they call care process. So, if you're in the system, we got all the bells and whistles, but we leave lots and lots of people behind.

 And so, as we think about going forward, we have the inflation reduction act, which is trying to make cancer care more accessible and more affordable for our patients. We've got administrative and economic pushback on that. We have a new administration that who knows what they're going to blow up going forward. But we know for sure. One of their priorities is not equal access to everybody around our country.

So, as we spend the next couple of months reflecting on where we've been and where we're going, fingers crossed, that reason will prevail, that we will prioritize the patients in general. That access does matter that we want to level the playing field to health care as much as we can for all of our patients across our great nation. And I think with that, we will show how we can work together and how we can bridge our divides as we walk forward over the next 4 years. John Marshall for Oncology Unscripted.

Continue on to the next segment to watch my interview with the one and only Dr Anthony Fauci!

This transcript has been edited for clarity.