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By Monica Soni, MD
Imagine you’re a Medicare beneficiary who has just received a devastating cancer diagnosis. You’ve been told that your best odds to prolong your life is to take one of the many new oral therapies that have reached the market in the last decade.
When you stop by the pharmacy, you find it is going to cost you roughly $3,000, and every month for the remainder of the year it will be another several hundred dollars. There is no annual out-of-pocket maximum, a fact that looms large as you wonder what other drugs you might need in the future. You’re not wealthy, but your income is also above the threshold to qualify for financial assistance. Do you pay for the drug? Is it worth it?
This scenario is one that is faced increasingly by cancer patients—and particularly Medicare beneficiaries with Part D prescription drug plans. For the purposes of high-cost cancer medications covered under Part D, many Medicare beneficiaries are functionally underinsured. Patients not only deal with a huge financial burden when prescribed these drugs, but they also have to face a massive emotional burden when deciding what to forgo to afford them.
Decisions to abandon cancer prescriptions—or not to fill a prescription in the first place—may become more common as oncology consumes a growing share of Part D spending. Targeted cancer drugs are increasingly picked up at the pharmacy counter rather than delivered in an oncology practice. Oral cancer medications, many of which cost Medicare beneficiaries more than $10,000 a year (and significantly more than that to the government), made up about 60% of the 83 targeted cancer drug indication approvals from 2011 to 2018.
For all their out-of-pocket expenses, patients should have confidence that their prescription cancer medications will help them live longer, enjoy a higher quality of life, or both. Yet, a new study in JAMA Internal Medicine offers a reality check. Among 44 new oral targeted cancer drugs that were dispensed between 2011 and 2018, just 11 had a documented survival benefit. Over those years, the portion of patients getting oral cancer drugs without demonstrated survival advantage increased from 13% to 59%.
This proliferation of clinically uncertain oral cancer therapies, along with the financial stakes to patients, paints a sobering picture. What can oncologists and health plans do?
Before providers prescribe these drugs, they need to be sure they’re using them judiciously, balancing both cost and efficacy, to increase the chances for longevity and quality of life for patients. For example, some drugs have demonstrated survival benefit in randomized controlled trials while others have only demonstrated benefit on surrogate endpoints, such as the ability to shrink tumors.
This is a reminder of the challenge to deliver true person-centered care. The ideal treatment plan factors in patients’ values, wishes and goals, as well as their financial health, to reflect what is best for that individual.
Patients may ultimately decide to spend thousands of dollars a year even if the survival data is immature. But they have a right to get this information ahead of time and ideally to use the doctor’s office as a safe, supportive space to debate whether to proceed.
The financial toxicity of Part D drugs is, in part, a problem of government health policy where reform could be transformational. Last year, Congressional Democrats announced a deal, as part of their Build Back Better spending plan, to limit annual out-of-pocket costs for Part D beneficiaries to $2,000 a year beginning in 2024. Their legislation would have also allowed Medicare to negotiate prices on a very limited number of high-cost drugs.
Given the roadblocks that legislation has hit, it’s far from guaranteed that the larger bill or its drug-cost provisions will gain final passage. However, if they do, it could dramatically change the calculus for Medicare beneficiaries when deciding whether they can afford a prescription drug. At the same time providers would then be able to act more effectively as counsel when determining the best course of treatment for the individual.
About The Author
As Associate Chief Medical Officer at New Century Health (NCH), a specialty care management company, Dr. Monica Soni works to ensure high-quality, cost-effective care for patients and the best possible experience for providers. She is a board-certified, practicing internal medicine physician with over a decade of experience in both inpatient and outpatient safety net care. Immediately prior to joining NCH, Dr. Soni served as the director of specialty care for the Los Angeles County Department of Health Services, the second-largest municipal health system in the United States. She is also an assistant clinical professor within the UCLA Department of Medicine.
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