Strategies to Curb Drug Costs Affect Patient Care, Says ASCO

Roxanne Nelson, BSN, RN

April 20, 2017

Some of the strategies used by health insurance companies to control drug costs are having a negative impact on patients with cancer, says the American Society of Clinical Oncology (ASCO) in a new statement.  

While there is a need to control cost, it is also necessary not to undermine patient access to medically necessary care, ASCO states. Thus, approaches such as step therapy, specialty tiers in drug formularies, restrictive formularies, and nonparity of patient cost sharing for oral cancer drugs restrict patient access to high-quality, high-value cancer care.

ASCO points out that cancer care is unique in that interchangeable clinical options are often lacking and that "optimal cancer care requires patient access to the most medically appropriate drug at the most opportune time based on the highest quality evidence."

High-quality clinical pathways should be the first option to ensure appropriate use of anticancer drugs and the delivery of high-quality, high-value care yielding optimal benefits and outcomes, it adds.

"Utilization management strategies, when implemented without appropriate patient safeguards, can impede patient access to high-value, clinically appropriate care,"  ASCO President, Daniel F. Hayes, MD, said in a statement. "Payer policies must reflect the current requirements of contemporary cancer care and be evidence-based on what constitutes high-quality care."

This is not the first time that ASCO has warned about insurer policies.  Last year, it warned that insurers' demands for rigid adherence to inadequate, prespecified oncology protocols may have a negative impact on patient care and may cause administrative nightmares for many practices.

ASCO Recommendations

Some of the utilization management strategies in use are problematic and can affect patient access to the most appropriate therapy, ASCO warns in its new statement.

The policy of prior authorization requires patients or prescribers to receive preapproval as a condition of payment or coverage of the prescribed drug. This system can be problematic for many reasons, in that payers often do not disclose the process or basis for prior authorization determinations or that the individuals who make the prior authorization determinations may have only limited knowledge of cancer care.

In addition, because of the considerable length and complexity of the prior authorization, resources are drawn away from patient care to deal with the administrative burdens associated with this process.

The so-called step therapy or "fail first" policies require that patients use a drug from the payer's preferred list before coverage will be given for a different medication that the patient and physician prefer. In essence, payer-preferred product must be deemed unsuccessful before coverage will be provided for the regimen initially recommended by the treating physician.

Instead of these strategies, ASCO recommends the use of high-quality clinical pathways or coverage policies that are based on robust analyses of best clinical practices and existing scientific data.

Another practice being increasingly implemented is the placement of cancer therapies on the "specialty tier" of formularies, which in turn shifts a large portion of the cost from the payer to the patient.

Related to this is the strategy of using "restrictive formularies," in which payers limit the number of drugs that can be included within a category or class on a payer's drug formulary. The use of restrictive formularies, notes ASCO, are particularly problematic in oncology because cancer drug therapies often are not clinically interchangeable.

ASCO recommends against placing cancer drug therapies on specialty tiers  because imposing high cost-sharing burdens on patients with cancer, who may have limited treatment options, "is fundamentally unfair and counterproductive."

Along the same line, restrictive formularies can prevent a patient from being prescribed the best option and should not be a cost containment strategy for cancer drug therapies.

Finally, another problematic area is the unequal payment for oral vs intravenous or injectable drugs. Payers have imposed higher patient cost-sharing requirements on oral chemotherapy agents by covering them under the prescription drug benefit rather than the more generous medical benefit that covers intravenous or injectable cancer drugs.

ASCO believes that parity should exist for oral and intravenous drugs used in treatment regimens, and it has long advocated for oral parity legislation to address this issue to date. More than 40 states have enacted oral parity laws over the past decade.


Clinical pathways, says ASCO, which are appropriately designed and implemented, are evidence-based tools that can be used to deliver high-quality cancer care, and "payers, institutions, and clinicians use pathways to reduce variabilities in treating specific conditions and control costs."

However, there have been concerns that not all clinical pathways in oncology have been developed and implemented in a high-quality, transparent, and efficient way, and their rapid proliferation has created an overwhelming and counterproductive administrative burden for many physicians.

Even though it supports the use of high-quality clinical pathways in oncology as a strategy to promote high-value care, ASCO emphasizes that pathways need to be developed and deployed in accordance with ASCO's criteria, which promote patient protections for clinical pathway development, implementation and use, and analytics.

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