Payers fund trials of cheaper, shorter or lower-dose versions of expensive treatments
Health insurers and national health systems have every reason to find out whether half the dose or half the duration of a costly drug works as well. They would fund those trials directly and keep the savings.
Payers commission pragmatic randomised trials of dose reduction, shorter duration, extended dosing intervals, stopping rules and cheaper alternatives for high-cost oncology drugs, embedded in routine care with registry endpoints. No manufacturer will run these; academic groups lack money. Precedents include the UK's REFINE-Lung (reduced-frequency pembrolizumab), the Netherlands' payer-supported trials of lower-dose abiraterone and dose-reduced ibrutinib, and the Dutch SONIA trial on CDK4/6 sequencing, whose savings dwarfed its cost. A standing payer trials fund with a savings-reinvestment rule would make this systematic.
- Incentives reward me-too drugs and marginal gains · The system pays the same for a drug that adds two months as for a cure, so companies race to copy rather than to cure.
- Wrong doses · Most drug doses were chosen as the highest a person can tolerate, which is often more than they need.
- Prices and value · New cancer drugs routinely cost over $150,000 a year, often for months of benefit. Systems cannot afford them and patients go bankrupt.
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