ANTICANCER TREATMENT PARITY

To support anticancer treatment parity legislation at both the state and federal level that ensures equality of access and insurance coverage for all anticancer drug products approved by the Food and Drug Administration (FDA); further,

To advocate all insurers and manufacturers design plans containing limits on out-of-pocket expenditure so that patient cost sharing for anticancer treatment is equivalent, regardless of treatment modality or route of administration; further,

To encourage the development of policies and endorse practices that contribute to a decrease in anticancer treatment costs to the consumer; further,

To continue to foster the development of best practices, including adherence monitoring strategies, and education on the safe use and management of anticancer agents, regardless of route of administration.

Rationale

An estimated $200 billion will be spent on cancer care by 2020, and a recent survey showed if faced with a cancer diagnosis, 57% of Americans say they would be most concerned about either the financial impact on their families or about paying for treatment. Additionally, there is an increase in insurance premiums, co-pays, co-insurance, and deductibles. Most insured cancer patients in the U.S. are responsible for a portion of the cost of their anticancer agents, which can be significant. The average out-of-pocket expense for Medicare patients with cancer is 23.7% of household income. Cancer survivors are 2.7 times more likely to file for bankruptcy.

 Traditionally, intravenous (IV) and injected treatments were the primary methods of chemotherapy delivery. Patient-administered anticancer agents have become more prevalent and are now the standard of care for many types of cancer. Oral anticancer agents account for approximately 35% of the oncology development pipeline. Many oral anticancer agents do not have infusible or injectable alternatives and are the only treatment option for some cancer diagnoses. Oral agents have been embraced because of convenience, efficacy, and safety, but because insurers cover them differently than intravenous drugs, prescribing oral anticancer agents can impose burdensome levels of cost-sharing on patients.

While IV anticancer treatments are covered under a health plan’s medical benefit, often requiring patients to pay a minimal co-pay or no cost at all for the medication, oral anticancer agents are usually covered under the pharmacy benefits. This results in increased out-of-pocket costs. Cost sharing of oral specialty drugs has increased from 3% in 2004 to 25% in 2013 and continues to rise.

The impact of rising out-of-pocket prescription costs for cancer patients can negatively affect adherence and subsequently treatment outcomes. Co-pays can be hundreds or thousands of dollars per month and, as a result, almost 10% of patients choose not to fill their initial prescriptions for oral anticancer agents. A study of claims data from more than 38,000 people who received a new prescription for one of 38 oral anticancer agents from 2014 to 2015 found that, as out-of-pocket costs rose, fewer patients filled their prescriptions. When the required co-pay was less than $10, only 10% of patients failed to pick up their prescriptions. This increased to 32% for patients whose out-of-pocket costs were between $100 and $500, and to 41% when costs were between $500 and $2000. When the out-of-pocket costs exceeded $2000, nearly half of patients (49%) never filled their prescriptions. Delayed initiation of treatment was also significantly higher for those with higher cost-sharing burdens.

Oral parity is a proposed legislative solution to alleviate coverage discrepancies between oral and intravenous anticancer agents. Parity laws are designed to ensure that orally administered agents for treating cancer are not more costly for patients than anticancer agents given via infusion at a clinic or hospital. At this point, 43 states and Washington, DC, have enacted parity laws that require patients to pay no more for an oral cancer treatment than they would for an infusion. Studies conducted in states with parity laws have generally showed an increase in treatment utilization, which have been found to reduce mortality rates in some instances.

However, state parity laws only apply to certain commercial health insurance plans, including those purchased by small groups and individuals. Self-funded patients, patients covered by health plans that fall under federal law (large, multi-state health plans), or those covered by Medicare and other federally funded insurance plans are not eligible. An estimated fifty percent of cancer patients are currently not protected under state parity laws.

The Cancer Drug Parity Act of 2019 (H.R. 1730, introduced on March 13th, 2019; formerly introduced in 2017 as H.R. 1409) would require any health plan that currently provides coverage for cancer treatment to provide coverage for self-administered anticancer agents at a cost no less favorable than the cost of IV, port-administered, or injected anticancer agents. The Cancer Drug Parity Act of 2023 (S. 2039) was recently introduced to the senate on June 15, 2023. It is proposed as a bill to amend the Employee Retirement Income Security Act (ERISA) and group health plans it supports. Medicare patients are not currently covered by this legislation, though Medicare is undergoing significant changes to combat the same problem of exorbitant out-of-pocket spending on oral medications.

There may be false patient perception that oral anticancer agents are less dangerous than IV chemotherapy, further supporting the important role of the pharmacist in educating the patients about the agent, its adverse effects, how to manage toxicities, and when to contact their healthcare team. Pharmacists monitor oral chemotherapy treatments to prevent medication and food interactions, adverse drug reactions, and medication errors. Pharmacists are also positioned to play an integral role in shared decision-making and assisting with procurement.

Treatment of cancer also continues to evolve, and many agents may not fall under the category of traditional chemotherapy (e.g., biologic agents, antimicrobials, and others). As a result, practitioners and legislatures have moved away from the singular term chemotherapy and use chemotherapy, anticancer and cancer drug interchangeably, with anticancer being the preferred term.