“I Can’t Afford Any More Advances in Cancer Care, Doc!”

January 29, 2013

The reality is that new biological agents are often priced like a Ferrari, and patients who are covered under a pharmacy benefit are required to fork over not a fixed copay but a percentage of the pill’s cost, each and every month ‘til eternity or death, whichever comes first.

One of my patients stopped by this afternoon and, not seeing him on my schedule, I asked my nurse what was the occasion.

“He’s picking up his abiraterone prescription,” she said. Then, with the slightest hesitation she added, “His copay is $2,300 this month, and it will go up even more after that.”

The look on my face, according to witnesses, was identical to one who just realized that he had left his wallet in an airport restroom-$2,300 per month for a pill? Granted, this new treatment for metastatic castration-resistant prostate cancer is a major advance, as well as a paradigm for exploiting the tumor’s addiction to androgens; in my patient’s case, abiraterone will double his progression-free survival compared to placebo. The cost, however, takes one’s breath away. Why is this oral medicine, as well as many other exciting new drugs, so expensive to patients?

Those who follow health care insurance updates know the answer-while intravenous chemotherapy is covered as a medical benefit by payors, which therefore limits patient copays and caps the annual overall expense at a certain amount, oral anticancer medicines are reimbursed as a pharmacy benefit. The reality is that new biological agents are often priced like a Ferrari, and patients who are covered under a pharmacy benefit are required to fork over not a fixed copay but a percentage of the pill’s cost, each and every month ‘til eternity or death, whichever comes first. Doing the math at 25%, we conclude that my patient is on a drug that costs $9,200 per month. Yikes!

Doesn’t seem fair, does it? You are not the only one to conclude this. Eighteen states and the District of Columbia have passed laws forcing health insurance companies to cover oral anticancer medications “under terms no less favorable” than those that are administered intravenously. This concept is called oral parity. It is designed to rectify the obvious conclusion that the more money cancer patients have to pay out of their own pocket, the less likely they are to receive their treatment. The converse of this conclusion is called “ensuring access to cancer care,” and I dare you to show me one person in America who doesn’t support such a noble cause.

Ahem-actually I can show you several persons, and they just happen to run health insurance companies. Their response to oral parity has been, to be generous, inconsistent. Payors claim that oral parity laws are a forced mandate to provide benefits, but they are in favor of the Obamacare mandate that all individuals purchase their health insurance. Payors claim that oral parity laws will drive up insurance premiums, but premiums are already rising since the passage of the Affordable Care Act, and according to a detailed report by the Milliman consulting group, parity will raise the average cost of a commercial plan at most by only 0.16% ($0.50 increase per member per month [PMPM] in a $300 PMPM plan).

The advances in oral biological agents that can arrest the growth of obdurate cancers like malignant melanoma are nothing short of well, let’s just say promising. Let’s even say extremely promising. Research uncovers more and more targets on cancer cells that dare us to try and disable them, and we are happy to take up that dare. With the unraveling of the human genome, medical oncology has an opportunity to fulfill the definition of evolution: “a process of continuous change from a lower, simpler, or worse, to a higher, more complex, or better state.” In the fight against cancer, oral targeted agents represent the great leap forward. In order to make this a reality, not to mention continue the complex process of improving efficacy, these medications must reach their intended patients with a minimum of obstruction. Without oral parity, the new horizon in cancer treatment is at risk for stagnation, and if stagnation slows its evolution, medical oncology may eventually limp toward extinction.