Cancer Patients Forgo Therapy Because of High OOP Costs

Roxanne Nelson, RN, BSN

December 22, 2017

Many new cancer drugs are now taken orally. These drugs offer patients the convenience of taking the drug at home instead of having to travel to a clinic or a hospital for infusions.

However, oral cancer drugs also have a major disadvantage ― high out-of-pocket (OOP) costs. These costs can be so high that some patients abandon treatment.

A new study found that when the OOP cost was less than $10, only 10% of patients abandoned their therapy and failed to fill their prescription. However, this number tripled, to 32%, when the OOP charge was $100 to $500, and it rose even higher, to almost 50%, when the patient's cost was more than $2000.

Patients were considered to have abandoned treatment if they did not begin taking the oral medications during the next 3 months.

The study was published online December 20 in the Journal of Clinical Oncology.

"More and more patients are responsible for high out-of-pocket prescription costs, but they may not be aware of their obligations," said lead author Jalpa A. Doshi, PhD, a professor of general internal medicine in the Perelman School of Medicine, the University of Pennsylvania, Philadelphia, and director of value-based insurance design initiatives at the Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, the University of Pennsylvania.

"It is important to raise the possibility of financial barriers and incorporate this into discussions of treatment options. Otherwise, patients may be at risk of abandoning treatment," Dr Doshi told Medscape Medical News.

She explained that proactive discussion of financial barriers, including helping patients to understand their OOP obligations, is likely to be helpful. "For example, refills may be less expensive once an initial deductible has been met," she said.

Dr Doshi noted that findings from a recent survey by CancerCare highlight that "patients are often overwhelmed at the time of diagnosis and may struggle to process the pros and cons of treatment options or communicate their preferences to the care team.

"They also may not realize there could be more than one treatment option," she said. "In light of this, it could be very helpful for a member of the care team to follow up with patients in the weeks after they have received a new oral prescription, to check for barriers such as out-of-pocket expense. If patients haven't filled their prescription, offering an opportunity to discuss alternative treatment options may also be helpful."

Uneven Coverage

Although in theory, oral drugs should be less expensive than drugs that need to be infused intravenously (IV), in practice, insurance models shift more of the cost onto the patient. These agents are generally covered through the pharmacy benefit of a plan, rather than the medical benefit, under which infused medications are covered. This discrepancy can require higher cost sharing for the patient. Medical benefits usually require patients to pay a flat copayment ($20 to $50 per visit) for care in an outpatient setting, and this can include the administration of IV medications.

Pharmacy benefits involve a very different arrangement. They often have a tiered copayment structure, and other provisions can boost cost sharing for more expensive medications. Because novel oral agents tend to be very expensive, they are frequently placed on specialty tiers that carry substantial OOP costs.

To even the playing field, 43 states and Washington, DC, have passed oral chemotherapy parity laws to ensure that cost sharing is equal for both oral and infused anticancer agents. But the outcomes from these laws are mixed; some patients have benefitted whereas others have not.

Study Details

Dr Doshi and her colleagues conducted a retrospective study of associations between OOP costs and reduced and/or delayed initiation of treatment with oral anticancer agents.

They used claims data from a large, proprietary, integrated database (2014-2015) that included Medicare and commercial insurance enrollees who had received a new prescription for any of 38 oral anticancer agents. The final cohort included 38,111 patients.

They found that 18% of patients abandoned their index oral anticancer agent (n = 6910). Demographics were similar between patients who abandoned the index prescription and those who filled it. The statistically significant differences tended to be minor, the authors note. On average, those who abandoned it had higher OOP costs in comparison with patients who filled it. For patients who abandoned the index prescription, the mean OOP cost was $1396.48 (SD, $2257.67; median, $432.04). For patients who filled their index prescription, the mean OOP cost was $284.00 (SD, $939.42; median, $3.36; P < .001).

Patients with the lowest OOP costs had the lowest rate of delayed initiation of their index prescription, compared with those in the highest OOP cost category, at 3% vs 18%, respectively. The mean time to initiation for patients who delayed filling their prescription was 34.8 days (SD, 18.4 days). This was similar across all cost categories.

The risk-adjusted rates of prescription abandonment were significantly higher in the higher-OOP cost categories. Overall, rates of not filling prescriptions for any other oncologic treatment (determined on the basis of an absence of evidence of the patient's receiving any oral, injectable, or infusible medication) were similar to the abandonment rates. This suggests, note the authors, that very few patients received an alternate therapy during the following 3 months.

"We did check to see if they received an alternate medication in the same drug class, but we did not examine older therapies or off-label therapies that patients could have received," said Dr Doshi. "Our data did not have information on whether patients received free medications from manufacturer assistance programs or opted to enroll in a clinical trial."

She pointed out that they also did not examine clinical outcomes and so could not speculate on survival or how these patients might have fared longer term.

"But regardless of clinical outcomes, having to settle for an alternate treatment that was not your oncologist's first choice, or perhaps your first choice, or having to navigate the maze of finding financial assistance or clinical trials adds substantial stress at an already very stressful time and could potentially impact clinical outcomes," Dr Doshi added.

Although similar associations between OOP cost category and drug abandonment were observed in all subgroup analyses, the absolute risk-adjusted abandonment rates were generally higher among commercially insured patients as compared with Medicare Part D beneficiaries and for other pharmacy customers as compared with customers of mail-order suppliers. Abandonment rates were lowest for drugs indicated for chronic lymphocytic leukemia and were highest for those indicated for metastatic renal cell carcinoma.

The authors designed a hypothetical scenario in which cost sharing shifted the patient's current OOP cost category to higher OOP cost categories. If the OOP cost of $50.01 increased to $100, the predicted abandonment rate doubled, from 16.0% to 35.9%. If the OOP cost increased to more than $2000, the estimated abandonment rate climbed to 54%.

The study was supported by Pfizer, the University of Pennsylvania's Center for Pharmacoepidemiology Research and Training, and the Automated Claims and Medical Record Databases core of the Clinical and Translational Research Award at the University of Pennsylvania. Dr Doshi has disclosed no relevant financial relationships.

J Clin Oncol. Published online December 20, 2017. Abstract

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