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Out-of-Pocket Costs Linked to Compliance with Oral Oncologics

DawnHershman98pxAccess and adherence to long-term cancer therapies are emerging as major public health issues around the world, as high out-of-pocket costs for oral anticancer agents are linked with noncompliance that can directly affect outcomes.

“Solutions should involve increasing access and reducing cost – especially out-of-pocket costs,” said Dawn L. Hershman, MD, MS, Professor of Medicine and Epidemiology at Columbia Medical Center, New York City. “In addition, there may be options with intensified pharmacy efforts which can identify barriers to access quickly.”

“Oncology care models that provide patients information regarding their out-of-pocket costs might also be a solution,” she added.

As Dr Hershman reported, in developed countries, adherence rates among patients suffering from chronic disease average only 50%. In developing countries, however, given the paucity of health resources and inequalities in care, the rates are presumed to be even lower.

“We need to think globally about this issue,” said Dr Hershman. “The striking impact of poor adherence is going to have an even greater magnitude where resources are scarce, leading to inequities in access to healthcare.”

Oral Adherence

Despite the efficacy of hormonal therapy, many women discontinue their medication or take their medication intermittently over the course of their treatment. One study of over 8000 women found that approximately 25% of patients discontinued their therapy and another 25% were taking their medication less than 80% of the time.

“Only about half of patients were taking the right amount of medication for the full duration of their treatment,” said Dr Hershman. “This has clinical implications; stopping therapy early for hormonal therapy impacts survival.”

Although much nonadherence stems from toxicity, cost is also a modifiable risk.

The cost of all oral medications has increased dramatically, from an estimated $40 billion in 1999 to $234 billion in 2008, said Dr Hershman, who noted that the cost of new oral agents now exceeds $10,000 per month.

“While use has not changed since 2006, spending on oral oncologics available in the US market has risen dramatically. Now, with the increase in approvals for oral medication, both of these are going to increase substantially,” she reported.

It’s not just the cost of drugs, however; insurance coverage and patient access to resources also drive adherence.

One study, using Medco data, found a significant association between prescription copayment and adherence, with patients over 65 years being most affected. For a 90-day supply, copays over $30 per month resulted in substantially decreased adherence, said Dr Hershman.

Another study, involving patients’ net worth, showed that adherence was best in patients with the highest net worth versus those with medium and low net worth.

“The amount that patients are spending on these drugs is increasing on a yearly basis,” said Dr Hershman. “In patients with CML [chronic myeloid leukemia], for example, copay requirements have risen substantially over time, along with the increased cost of tyrosine kinase inhibitors....Correcting these issues has the potential to improve disparities in outcome.”

Cost-Effectiveness of Full Coverage

By estimating the costs of patient nonadherence to their medication and the cost of treating metastatic cancer, one study suggests that it’s actually less costly to provide full prescription coverage for hormonal therapy, and when the model was adjusted for quality of life, there was also significant improvement.

“Compared with the current Medicare Part D Prescription Drug Benefit, eliminating patient cost sharing for aromatase inhibitors would improve health outcomes and save money,” said Dr Hershman. “The incremental cost of coverage for aromatase inhibitors could be offset by the cost reductions from cancer recurrences averted.”

Average cost reductions of approximately $275 per beneficiary would save society almost $17 million for the approximately 60,000 beneficiaries who receive treatment for breast cancer every year, Dr Hershman reported.

Future Solutions

Reducing the cost of drugs may be an economic imperative, said Dr. Hershman, but it must be done in a way that does not compromise innovation.

One potential solution is the Cancer Drug Coverage Parity Act of 2015, which states that a patient should not be made to pay more out of pocket for oral cancer medications than they are asked to pay for infusional drugs.

“This legislation would require health insurance plans that cover traditional chemotherapy to provide equally favorable coverage for orally administered anticancer medications,” Dr Hershman explained.

Another possible solution is to modify the cost-sharing requirements of the Medicare Part D Drug Benefit design so that, instead of 100% coinsurance, beneficiaries are responsible for only 50% until out-of-pocket costs reach $4700.

Although promising, these mechanisms are not currently in place, said Dr Hershman. “Ultimately, policy level efforts are needed to address these complex barriers to quality healthcare,” she concluded.

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