Insurers Decide to Cover Avastin - With Help From Roche-Connected Advisory Panel

by: Pharmalot

In a move that will hearten breast-cancer patients, several large insurers, including WellPoint (WLP), Aetna (NYSE:AET), Humana (NYSE:HUM) and UnitedHealth (NYSE:UNH), will continue to pay for Avastin as a breast cancer treatment even though the FDA is taking steps to remove that indication for the Roche (OTCQX:RHHBY) drug. The agency is doing so after analyzing clinical studies that found Avastin does not prolong overall survival or provide a sufficient benefit in slowing disease progression to outweigh serious side effects (back story).

Among the insurers still covering Avastin for breast cancer, UnitedHealth and WellPoint said they based their decision on a recommendation by the National Comprehensive Cancer Network, a non-profit group of oncologists whose guidance is closely followed. However, eight of the 33 members on its breast cancer panel have various ties to Roche and its Genentech unit as advisory board members, speakers, consultants, expert witnesses or having received clinical research support (see here). Genentech is also listed as a supporter. We should note the panel includes a few NCCN staffers.

The connections are not a secret - NCCN discloses this information for all of its panels and staff members on its website. Nonetheless, the links to Roche and its Genentech unit, which were noted in a Bloomberg piece, are apparently nothing that insurers want to discuss.

A UnitedHealth spokeswoman acknowleged that coverage is based on the NCCN recommendation, but did not respond to a question about financial ties to the drugmaker. A WellPoint spokeswoman wrote us that the insurer’s Hematology Oncology Subcommittee and the Medical Policy & Technology Assessment Committees will review trial data after publication, but for now will continue coverage based on what NCCN has to say. She declined, however, to discuss the links to Roche. Aetna and Humana declined to respond altogether.

In a conversation with us, NCCN CEO Bill McGivney says the group disallows anyone who might receive either more than $50,000 in total from outside companies or more than $20,000 from any one company from being a panel member. Why the $50,000 limit? That’s the same threshold established by the FDA for its advisory panels. And he adds that panel members can be recused from specific deliberations if a potential conflict of interest is detected, although this occurs infrequently.

“We have a pretty open or transparent process. We’ve worked closely with payers over the years. And they’re aware of the process for making recommendations. And if anyone would question the process, it would be them. Payers certainly have a vested interest, an extreme bias and a specific view, but they recognize us,” McGivney says.

But is it not possible to find panelists with no ties to a particular drugmaker for the purposes of making such a decision? This is the same question that has plagued the FDA for years. McGivney, who is used to fielding this question, offers a response that may sound familiar.

“I’m sure we could. We have thousands of oncologists at NCCN. I’m sure it would be possible to put together a panel with no association to Genentech … But these are the leading people in the world. We do not believe this specifically compromises their ability to fairly evaluate data …When you really look at it, the level of interaction with the biopharma industry, given the dollar amounts we talked about and functions they perform, is quite limited.”

Disclosure: No position