Public Release: 

High out-of-pocket costs may place oral cancer medications out of reach

Study finds half of patients with the highest out-of-pocket costs did not fill their prescription

University of Pennsylvania School of Medicine

PHILADELPHIA - Sticker shock may be leading many insured Americans with cancer to forego treatment with a wide range of oral cancer drugs, suggests a study published online this week in the Journal of Clinical Oncology. Led by researchers at the Perelman School of Medicine at the University of Pennsylvania, the findings point to high out-of-pocket costs as a barrier to potentially life-saving or life-prolonging treatments. As breakthroughs in cancer care continue, the study raises questions about whether patients will able to take advantage of new treatment options.

The study used a large database of prescription claims to track more than 38,000 people in the U.S. who received a new prescription for one of 38 oral cancer medications from 2014-2015, to see whether patients filled the prescription after it was approved by their insurance. All insurance types were included, including Medicare.

The researchers found that 10 percent of patients failed to pick up their prescription when they were required to pay less than $10, but this jumped to 32 percent among those who were charged $100-$500 and to nearly 50 percent among people whose out-of-pocket costs were more than $2,000. This was true even after taking other relevant factors into account, including type of insurance, pharmacy, and patient characteristics such as age and health status. There was no evidence that patients began treatment with the oral medications over the next three months, and so they were considered to have "abandoned" their prescription.

The relationship between high out-of-pocket costs and prescription abandonment remained consistent for all cancers, even for conditions where treatment can significantly extend life. When patients with higher out-of-pocket costs did fill their prescriptions, they were more likely to be delayed in doing so. Prior research has shown that insured people with other medical conditions often delay, interrupt, or discontinue their medications when faced with high out-of-pocket costs, but the authors say it's especially concerning to see this pattern with life-threatening cancers

"Patients in our study were facing a new cancer diagnosis or a change in their disease that required a new treatment. Imagine leaving your doctor's office with a plan, ready to start treatment, only to find you can't afford it," said lead author Jalpa A. Doshi, PhD, a professor of General Internal Medicine in the Perelman School of Medicine at the University of Pennsylvania, and director of Value-Based Insurance Design Initiatives at the Leonard Davis Institute's Center for Health Incentives and Behavioral Economics. "It adds more stress at what is already a stressful and scary time."

The advantages of oral medications include simpler administration and convenience, since they do not require a visit to the hospital or doctor's office (as is the case with older, intravenous chemotherapies). Yet oral drugs are typically covered under a separate pharmacy benefit, with more of the medication's cost often passed on to the patient through coinsurance that requires patients to pay a percentage of the cost rather than a fixed copayment. Complete payment is also due up front, instead of patients receiving a bill after their treatment session. These factors increase the risk of delayed access or treatment abandonment, the researchers said.

The study also examined whether patients who abandoned their prescription went on to initiate any other cancer drug in the same drug class in the following three months, including intravenous therapies. They found that few did.

"This shows the importance of discussing financial barriers up front, during conversations about treatment options, even with patients who don't raise concerns," Doshi said. "Patients may not be aware of how expensive their prescriptions will be, and physicians may not realize that a patient has opted not to fill the prescription."

One in eight patients in the study had out-of-pocket costs higher than $2,000, but patient obligations at that level have become even more common in the years since the data were captured. The commercial insurance market continues to trend toward high deductible health plans and use of higher coinsurance. Such high out-of-pocket prescription costs are typical for most Medicare patients at the beginning of the year, unless they receive low-income subsidies.

In light of these trends, the researchers illustrated what would happen if study patients' out-of-pocket costs shifted to a higher cost category. They found that if patients currently responsible for $50-$100 per prescription were to be charged $100-$500 instead - all other things being equal - abandonment rates would be expected to double.

"Our results highlight the pressing need for all stakeholders - including manufactures, pharmacy benefit managers, payers, and policy makers - to identify fiscally sustainable strategies to improve patient access to cancer medications," the researchers wrote.

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Co-authors on the study included Penn's Pengxiang Li, PhD, Hairong Huo, PhD, and Amy R. Pettit, PhD, and senior author Katrina A. Armstrong, MD, MSCE, of Massachusetts General Hospital in Boston.

This study was supported by Pfizer, and 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 Penn.

Penn Medicine is one of the world's leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania (founded in 1765 as the nation's first medical school) and the University of Pennsylvania Health System, which together form a $6.7 billion enterprise.

The Perelman School of Medicine has been ranked among the top five medical schools in the United States for the past 20 years, according to U.S. News & World Report's survey of research-oriented medical schools. The School is consistently among the nation's top recipients of funding from the National Institutes of Health, with $392 million awarded in the 2016 fiscal year.

The University of Pennsylvania Health System's patient care facilities include: The Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center -- which are recognized as one of the nation's top "Honor Roll" hospitals by U.S. News & World Report -- Chester County Hospital; Lancaster General Health; Penn Wissahickon Hospice; and Pennsylvania Hospital -- the nation's first hospital, founded in 1751. Additional affiliated inpatient care facilities and services throughout the Philadelphia region include Good Shepherd Penn Partners, a partnership between Good Shepherd Rehabilitation Network and Penn Medicine.

Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2016, Penn Medicine provided $393 million to benefit our community.

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