It will be easier for people with blood cancer and other serious conditions to get healthcare coverage under the Patient Protection and Affordable Care Act (ACA). However, the ACA permits variation among exchange plans, which could mean significant differences in services to people with blood cancer.
This report by Bruce Pyenson and Jane Suh provides an early look at the 2014 individual benefit designs and premiums for policies sold on state exchanges in California, New York, Florida, and Texas. The report also reviews which drugs, cancer centers, and transplant centers are covered and discusses the role of out-of-pocket limits, as blood cancer treatment can be expensive and out-of-pocket limits will not apply to non-covered treatments and treatment centers.
Cancer patients receiving active treatment with chemotherapy incur four times the costs of cancer patients not receiving chemotherapy. The cost of patients receiving chemotherapy has been reported to vary by site of service, with higher costs when treatment is delivered in a hospital outpatient setting (HOP) versus a physician office visit (POV). Recent reports indicate an increasing portion of chemotherapy is being delivered in HOP settings and less in POV settings, which can increase costs for payors and/or employers.
This study provides new information by examining Truven MarketScan® commercial claims data (index years 2009 and 2010) to calculate the episode cost of chemotherapy delivered in the HOP versus POV settings for specific disease states. HOP costs were 28% to 53% higher than the POV costs depending on the cancer and adjuvant or metastatic stage. In particular, we noted significantly higher per-episode cost for chemotherapy drugs, radiation oncology, imaging (CT, MRI, and PET scans) and laboratory services in the HOP setting.
This report was commissioned by Genentech.
Milliman’s actuarial research has played a key role in the establishment of an evidence-based case for lung cancer screening. The announcement by the U.S. Preventive Services Task Force (USPSTF) stating it will now recommend lung cancer screening for certain high-risk populations follows a series of actuarial studies that helped make the value case for such screenings.
The following reading list highlights the actuarial research and also provides links to other lung cancer-related content.
• An actuarial approach to comparing early stage and late stage lung cancer mortality and survival (subscription required)
This actuarial analysis of lung cancer mortality published in Population Health Management provides evidence that early detection of lung cancer generates genuine mortality reductions not associated with lead time bias, and therefore could reduce late stage deaths by over 70,000 people in the United States each year.
• An actuarial analysis shows that offering lung cancer screening as an insurance benefit would save lives at relatively low cost
Using actuarial models, this study published in Health Affairs estimates the costs and benefits of annual lung cancer screening if offered as a commercial insurance benefit in the high-risk U.S. population, ages 50 to 64.
• Improved lung cancer screening could lead to earlier detection
In this interview, the authors and sponsors of the first actuarial analysis of lung cancer mortality discuss the broader implications their research may have in the effort to reduce deaths associated with the disease.
• An actuarial analysis of lung cancer screening
This blog post highlights Bruce Pyenson’s presentation on lung cancer screening at Health Affairs’ “Value in Cancer Care” briefing in 2012.
Nebraska recently enacted a chemotherapy parity law requiring insurance companies to insure oral chemotherapy the same as intravenous cancer treatments. This article in the Lincoln Journal Star cites a 2010 study conducted by Kate Fitch, Kosuke Iwasaki, and Bruce Pyenson on the cost-sharing of oral and intravenous cancer drugs.
Here is an excerpt from the article:
Sen. Jeremy Nordquist of Omaha, who spearheaded the legislation in Nebraska, said the lack of parity in coverage between intravenous and oral chemotherapy medications is a growing problem. Some cancer treatments cost $5,000 to $10,000 a month, and some patients are being forced to pay high out-of-pocket costs for chemotherapy taken orally.
“This … will make life-saving cancer treatments more accessible and affordable for cancer patients,” he said. “The decision about the best course of treatment, whether it be IV chemo or chemo in a pill form, will be made between patients and their doctor, not dictated by their insurance company.”
Nordquist said research shows that when confronted with the reality of high out-of-pocket expenses, many cancer patients forgo expensive therapy and discontinue treatment, in part because they do not want to saddle their families with unmanageable debt.
And because oncologists know how expensive oral medications can be, he said, they often do not prescribe them — even when they think that would be the best option.
The actuarial and benefits consulting firm Milliman Inc. did a study in 2010 that estimated that requiring similar coverage for oral chemotherapy would cost less than $6 a year per person in most insurance plans.
To read the entire Milliman study, click here.
The Washington Post looks at oral oncology and the way insurers pay for such drugs. Here is an excerpt:
People who get traditional IV chemotherapy on an outpatient basis often pay a flat co-payment that covers the drug as well as the cost of administering it. Annual out-of-pocket costs are also typically capped.
Oral anti-cancer medications, on the other hand, are generally considered a pharmacy benefit. Instead of a co-payment, plan members often pay a percentage of the drugs’ cost — up to 50 percent, in some cases — with no annual out-of-pocket limit. And these drugs are expensive, often costing tens of thousands of dollars a year.
In recent years, states have stepped in to address the problem. Since 2007,
19 states and the District have passed laws requiring insurers to provide coverage for oral cancer drugs that is equivalent to infusion drugs, according to the National Patient Advocate Foundation. Five states, including Virginia and Maryland, have passed laws in 2012 alone, and others are considering proposals, according to advocacy groups.
Is oral chemotherapy a cost-effective way to treat cancer? The article addresses this question:
But oral oncology parity laws don’t necessarily drive up costs. According to a 2010 study by benefits consultants Milliman, the estimated cost to most health plans for complying with oral oncology parity laws would be less than 50 cents per member per month.
A new bill before the Nebraska legislature seeks to achieve parity between how insurance policies handle chemotherapy administered by IV versus chemotherapy administered via oral medications. Here are some details from an Association Press article:
The measure by Omaha Sen. Jeremy Nordquist seeks to address what supporters see as a disparity between how the two cancer treatments are classified: Insurance policies usually cover the cost of IV chemotherapy as a medical benefit, while oral medications are viewed as prescription drug benefits with much larger copayments.
Nordquist said the idea for the bill came from his brother, an Omaha oncologist, who reported encounters with roughly half a dozen patients who could not afford the preferred cancer treatment in pill form. He pointed to a study by Milliman Inc., a national health care consulting firm, which found that the per-payer increase ranged from 5 cents to $1.50.
To see the full Milliman report on oral chemotherapy, go here.