Health & Family

Carolinas patients pay more for oral chemo

Cancer patients pay more out-of-pocket for pills than they do for infusions or injections because of differences in insurance coverage for medical care and pharmacy benefits.
Cancer patients pay more out-of-pocket for pills than they do for infusions or injections because of differences in insurance coverage for medical care and pharmacy benefits. dlaird@charlotteobserver.com

North Carolina is one of only 11 states where cancer patients who get their treatment in pill form pay much more than those who get chemotherapy by infusion or injection.

That difference has come under attack by patient advocates who are pushing for a state law to require insurers to apply the same out-of-pocket requirements for patients no matter which way they get treatment.

By taking pills, patients can avoid hours of sitting in clinics getting intravenous drugs, but they may also be charged thousands of dollars more.

“It should not matter what method of chemotherapy a cancer patient is receiving, whether it’s an IV infusion or a pill,” said Christine Weason, the North Carolina government relations director for the American Cancer Society Cancer Action Network. “It’s just about fairness.”

Thirty-nine states and the District of Columbia have passed “oral chemo parity” laws to eliminate the perceived penalty to patients. Neither North Carolina nor South Carolina have such laws, but in April the North Carolina House passed a bill to require that insurance coverage for pills should be “no less favorable” than coverage for infusions or injections.

The bill is pending in the Senate rules committee. In 2013, the House passed a similar bill but Senate leaders refused to consider it.

Opponents say the bill would just shift costs to insurers without addressing the high cost of prescription drugs.

The difference in out-of-pocket cost between pills and injections results from a quirk in health insurance.

Under most insurance plans, chemotherapy delivered through infusions or injections in a doctor’s office or hospital clinic are covered under the medical benefit. But newer, more expensive cancer drugs in pill form are typically covered as a pharmacy benefit, under separate plans with higher cost-sharing requirements for patients. In recent years, oral medications have become more widely available – and in some cases preferable for convenience and effectiveness – to infusion therapy.

Mark Coggins, policy adviser for North Carolina Rep. David Lewis, R-Harnett, who sponsored the House bill, expects the Senate to act after it completes the budget process. “We are hopeful,” Coggins said. “There have been very productive talks…The Senate just is very measured in how they move bills.”

Supporters call for fairness

Supporters of “oral chemo parity” include the American Cancer Society, Susan G. Komen for the Cure and Community Oncology Alliance, a national organization of cancer specialists who are not employed by hospital systems.

Weason said infusion therapy was the only option for cancer patients until recently. Now that drugs in pill form are becoming more available, they also may be preferred because they typically have fewer side effects. “People can have a better quality of life,” Weason said.

She and other parity advocates would like to see a $100 a month cap on the patients’ out-of-pocket costs for oral chemo drugs. They cite studies showing that cancer patients won’t fill their prescriptions if the cost goes too high.

For example, a 2012 study by Prime Therapeutics, a pharmacy benefits manager owned by 13 insurance companies, found patients with out-of-pocket costs greater than $200 a month were at least three times more likely not to fill their prescriptions than those with costs of $100 or less. The study recommended “setting a maximum member cost share of $100 to prevent prescription abandonment.”

Opponents call it cost shifting

Blue Cross and Blue Shield of North Carolina, one of the owners of Prime Therapeutics, opposes the parity bill, calling it a “mandate” that would increase overall health care costs and insurance premiums.

“From our perspective, this bill is not about fairness,” said Blue Cross spokesman Lew Borman. “This bill shifts the cost from the (Blue Cross) member to the premiums of all members. ... (It) is not really about parity, it is actually about cost shifting.”

The bill does not address the skyrocketing cost of cancer drugs, Borman said. In fact, he said it “hides the costs” by requiring insurers to reimburse more for the drugs and insulating patients from the cost.

Indeed, the bill wouldn’t affect some people with insurance. It would not apply to those on Medicare or to those who get insurance from self-insured employers, said Estay Greene, director of corporate pharmacy for Blue Cross of North Carolina.

Efforts to address oral chemo parity at a federal level have been unsuccessful so far. Bills have been introduced in Congress three times in recent years, most recently two weeks ago, according to Rebecca Birch, Komen’s state advocacy and policy manager. Because the federal lawmaking process is slower, she said Komen supports passage of state laws to address the disparity. Depending on its final language, a federal law could apply to Medicare patients and others not affected by state laws.

Randy Watson, 84, a retired electrical products salesman, is a Medicare patient whose entire chemotherapy bill was covered when he was getting infusions. But he learned about six months ago that his cancer had spread outside his prostate, and his doctor prescribed an oral medication called Xtandi.

Watson got the first month’s supply of pills – about $11,000 worth – free, with help from financial advisers at his Charlotte doctor’s office. Although they were more convenient to take, he’ll have to figure out how much he can afford.

“Eleven thousand (dollars) a month, that’s a lot of money,” he said. “I don’t want to ruin what I leave for the kids. But at the same time I want to get a couple more months or years out of life.”

Premium increases predicted

In North Carolina, Blue Cross supported an amendment that would have placed a $500 cap on co-pays for oral chemo drugs, but it was voted down. Green said it was opposed by the pharmaceutical industry. “They prefer for the general public not to know the price of these drugs. They’re delighted with hiding the costs.”

Greene added that drug manufacturers offer coupons for brand-name drugs to help customers who qualify based on income and assets get treatment until they reach their deductibles and insurance reimbursement kicks in.

Borman added that the federal Affordable Care Act limits out-of-pocket expenses for people with insurance, so that a separate limit on payments for oral chemo drugs should not be needed. The ACA’s out-of-pocket limit is $6,600 for an individual and $13,200 for a family.

But Weason said that limit isn’t much help, depending on when patients are diagnosed. If they’re diagnosed near the end of a year, they would have to meet out-of-pocket limits for that year and then start over in January, and if the prescribed drug is not on the insurance plan’s formulary, that would make it out-of-network, and patients might have to pay 100 percent of the cost, regardless of the ACA’s out-of-pocket limit.

In states that have approved oral chemo parity, Weason said insurance premium increases have been “zero to negligible.” In North Carolina, even without oral chemo parity, Blue Cross recently announced it’s seeking a 25.7 percent rate increase for customers covered under ACA.

“Thirty-nine other states can’t be wrong,” Weason said.

Garloch: 704-358-5078

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