Access to combination oncology therapies: Enough talk, it’s time for action

Originally published January 2023. Updated November 20, 2023.

Last week, the UK Competition Authority published guidance that they would not prioritize competition investigations into companies in good faith working toward combination therapies.

Today we have both guidance from competition authority as well as practical and pragmatic ways forward using technology that bypasses problematic collusion in the same way these deals are done in finance. There is now no reason to delay; the time for access to combinations is now.

My colleagues and I have been working on how to apply technology infrastructure from the financial industry to solve some of the most thorny challenges in market access. While we certainly don’t have all the answers for every situation, we are seeing some promising outcomes as we work with a number of HTA organizations, payers and pharma companies.

One such area where success is within reach is combination cancer therapies. After multiple taskforces, summits, discussions and pilots, workable solutions are known, and its time to put these solutions into practice.

THE PROBLEM OF COMBINATION THERAPY ACCESS

In Europe and most of the world, it’s well accepted that payers will reimburse a new therapy at a price based on the value the drug delivers. As an example, in the UK, a drug that extends someone’s life one year in perfect health might be reimbursed at $30k; if it adds 2 years in perfect health, $60k, and so on. As an American living in Europe, it seems an elegant solution to the drug pricing problems we have in my home country.

But there are a few cases where applying this type of approach is increasingly problematic; one of which is combination therapies for cancer. Suppose I have cancer. If I get Drug A it will extend my life one year (reimbursed at $30k) and if I get Drug B it will extend my life one year (also reimbursed at $30k). Which treatment will my doctor give me? She’ll see a a study that shows that giving them together for my type of cancer extends my life 1.5 years, instead of one year. So that’s what she’ll recommend.

Well, here’s the problem. In many payer contexts, this combination therapy would be denied. In the UK example, the payer is forced to answer, “each of those drugs are cost effective at a maximum of $30k; 1.5 years is worth $45k, not $60k, so it’s not cost-effective for you to have both drugs together.” It’s a pretty sad situation for patients and no one’s fault directly that there is no access to certain evidence-based combination cancer treatments, but this has to change.

SOLUTION FOR COMBINATION THERAPY PRICING

Solving this problem boils down into three parts, each of which are understood and have actionable solutions:

• WILLINGNESS FOR DIFFERENTIAL PRICING A PREREQUISITE
  In the HTA context, we recognize that extending life 10 years is of different value from extending a patient’s life for 1 year. When literature shows the same therapy achieving different outcomes in different cases (for instance in combination or mono therapy), logical consistency requires us to recognize that the price of a certain drug must vary accordingly. Once we are willing to engage on differential pricing of therapies, we can move on to how exactly to define value to fit the cost of a therapy with a given payer’s constraints to pay for positive outcomes.
• SETTLEMENT INFRASTRUCTURE IS REQUIRED
  One reason differential pricing is scary is that combination, outcome based and other deals where differential pricing is involved requires infrastructure to be settled and monitored at scale, in many contexts confidentially. While there is both a technical and governance aspect to this, we should move forward quickly on both fronts as to avoid further delays for patients. The technical infrastructure exists and is ready for deployment.
• DEAL-MAKING MUST INHERENTLY BYPASSE PROBLEMATIC COMMUNICATION
  Even as the 2023 UK competition statement deprioritizes investigations into companies working in good faith to get combination therapies to market, it’s best to use technology, such as CCX, that avoids these issues altogether. As the Swedish Competition Authority astutely observed in their 2019 opinion on this matter, solutions to combination therapies should operate within competition law. Rather than await waivers from competition law to faciliate combination therapies, we should use tried and true approaches such as digital exchanges that inherently bypass any such problematic communication on pricing combinations by otherwise competitive companies. This process is well established in banking and finance, where contingent commitments are offered electronically and become binding when all parties have blindly and unilaterally submitted what they are willing to do to the exchange, not involving any communication among each other. Whether we use value attribution frameworks such as proposed by Takeda or others, any infrastructure for deal-making should follow a process that allows companies to talk in a ‘clean’ way without falling foul of competition law communication rules.

The buiding blocks for pricing combination therapies in a way that is sustainable and consistent in the HTA context are at hand, It’s now high time we move from thinking about it to getting it done. If you have thoughts on this or are interested in collaborating in this work, I’d love to hear from you and share more of what my team and I are learning. Timely access to combination cancer therapy is a really important problem to solve everywhere. In healthcare there are a lot of issues that don’t have solutions — this one does. Let’s work together to make it a problem of the past.

Nathan Sigworth is CEO of CCX, a company building technology that powers the implementation and coordination of market access both globally and locally