The cost of care for breast cancer patients continues to create barriers in access to screening and treatments. High cost-sharing is a barrier to care, as it prevents patients from accessing the screening and treatments prescribed by their physicians or forces physicians to make decisions based on outdated health plan benefit designs rather than what is best for the patient. To ensure that patients and their physicians can choose the most beneficial treatments, Komen advocates for policies to reduce insurance barriers that shift costs to patients, preclude physician decision making and place unnecessary burdens on accessing care.
Breast cancer patients and physicians should have the opportunity to choose the best drug therapy without the burden of overly restrictive cost containment policies.
Oral Oncology Parity
While intravenous (IV) drug therapy is a more well-known component of cancer treatment, an increasing number of cancer drugs today are orally-administered. Insurance coverage has not kept pace with innovation and the growing trend towards orally-administered anti-cancer drugs. The result has been patient cost-sharing obligations that are much higher for oral anti-cancer drugs than for drugs delivered through IV administration.
This disparity in cost-sharing exists because health insurance coverage for IV-administered drugs is typically provided under the plan’s medical benefit, but oral drugs are often covered under the plan’s prescription benefit, which involves much higher out-of-pocket costs than medical benefit plans.
As the cost of health care continues to rise, an increasing number of health plans are transferring the cost of certain prescription drugs to patients in the form of cost-sharing, including higher co-payments and coinsurance. Patients living with serious conditions, like breast cancer, are experiencing financial hardship due to the growing practice of insurers placing drugs in specialty tiers.
Placing therapies on the specialty tier requires patients to pay a percentage of drug costs instead of paying a fixed copayment, known as coinsurance. Specialty tier coinsurance rates can vary from 20 to 50 percent or more. This can result in making life-saving treatments literally inaccessible to patients. Drugs in this tier are not consistently defined, but are typically high-cost and require special dosing or administration, consist of complex molecules and/or are biologics.
Step therapy, sometimes called “fail first”, requires a patient to first try a preferred (often generic alternative) drug prior to receiving coverage for the originally prescribed drug. Step therapy is a method of utilization management health plans employ to control costs by beginning treatment with the most cost-effective drug therapy and then progressing to the newer, more costly treatments only if necessary.
The recent approval of generic drugs for cancer treatment, including aromatase inhibitors, has allowed health plans to employ step therapy and require the use of generics as a first-line therapy. Physicians are faced with considerable challenges in identifying drugs subject to step therapy due to the varying formularies and protocols established by health plans and pharmacy benefit managers. Unfortunately, there is no standardization in how the protocols are employed, leading to burdensome steps for physicians and delayed treatments for patients.
Traditional screening mammography is used for all asymptomatic women; after a lump or other signs or symptoms of disease have been found, diagnostic mammogrpahy is used. Additionally, diagnostic mammograms are typically recommended for women that have a prior history of cancer. Diagnostic mammograms can also be used to evaluate changes found during a screening mammogram or to view breast tissue when it is difficult to obtain a screening mammogram because of special circumstances, such as the presence of dense breast or breast implants.
Diagnostic mammography is coded differently than a screening mammogram, and are typically more expensive because additional x-rays are required to obtain views of the breast from several angles. As a result, patients may be required to pay higher co-pays, co-insurance and other cost-sharing mechanisms when receiving diagnostic mammograms, unlike with screening mammograms which are fully covered in Medicare, Medicaid and most private plans.
Reducing out-of-pocket costs for diagnostic mammography would improve access and allow more timely diagnosis and treatment of breast cancer. Additionally, lower out-of-pocket costs would reduce the financial burden on patients with a prior history of breast cancer who typically require diagnostic mammography as routine maintenance of survivorship.
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