Medicare Policies Must Fix Cost Sharing Under Part D, Expert Writes

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Stacie B. Dusetzina, PhD, is the Ingram Associate Professor of Cancer Research at Vanderbilt University Medical Center, and a member of the editorial board for The American Journal of Managed Care®.

A Vanderbilt University health policy researcher calls for modernization of Medicare policies to control or cap out-of-pocket costs for seniors, as more high-cost cancer drugs are managed under the Part D program.

Stacie B. Dusetzina, PhD, who is the Ingram Associate Professor of Cancer Research at Vanderbilt University Medical Center, addresses this topic in an essay, “Your Money or Your Life — The High Cost of Cancer Drugs under Medicare Part D,” published today in the New England Journal of Medicine.

Dusetzina, who is also a member of the editorial board for The American Journal of Managed Care®, writes that up to half of all cancer drugs are now given as oral agents, which means they are no longer billed as a medical benefit but instead are billed a pharmacy benefit under Medicare Part D. Although Dusetzina does not address this directly, there have been reports that use of oral oncolytics increased during the pandemic, as physicians sought to reduce cancer patients’ risk of COVID-19 exposure.

For younger patients, Dusetzina notes, increased use of oral cancer agents might not be noticeable. But this shift matters a lot for older patients due to Medicare’s cost-sharing rules—and older patients are more likely to develop cancer. “Most beneficiaries would be responsible for high (and unlimited) out-of-pocket spending for drugs filled under their pharmacy benefit,” or Part D.

These same seniors have typically taken steps to protect themselves from unexpected medical cost under Medicare Part B, as 90% have supplemental coverage to cover most out-of-pocket costs under the medical benefit. But that’s no help with pharmacy benefit.

Dusetzina illustrates the problem by comparing 2 first-line treatment scenarios for patients with common types of newly diagnosed metastatic breast cancer:

  • A patient with HR+, HER2-negative cancer might be prescribed 2 oral drugs—an aromatase inhibitor and a CDK4/6 inhibitor. Although aromatase inhibitors are now available in generic form, CDK4/6 inhibitors are new, and the cost listed was $3100 out-of-pocket for the first fill, with more than $10,5000 for 1 year of use, if the patient did not quality for low-income subsidies.

  • By comparison, a patient with HER2-positive cancer would be given a combination of trastuzumab, pertuzumab, and a taxane. Because these drugs are administered by a physician, they are covered by the patient’s medical benefit. “For beneficiaries with supplemental coverage, the medications would be subject to an out-of-pocket spending limit or would be covered with limited or no cost sharing,” Dusetzina writes.

She notes that in both scenarios, the patients received the current standard of care, with each physician prescribing based on the patient’s subtype of breast cancer. But one patient would face significantly higher out-of-pocket costs because the most appropriate treatment happens to be an oral agent.

Cost-sharing rules in Medicare Part D, she writes, must be viewed in light of typical incomes for seniors, which can be quite low—although incomes may be not quite low enough to qualify for subsidies.

The patient prescribed the CDK4/6 inhibitor, for example, might pay half her annual income for this drug alone, Dusetzina writes, “not including payments for premiums and other needed medical care. Asset limits, including limits on retirement and investment savings, may further constrain access to subsidies among older adults.”

Medicare Part D out-of-pocket spending caps, or policies that would allow the cost of the initial fill to be spread out over 12 months could make a difference for patients with limited incomes, she writes. The Center for Medicare and Medicaid Innovation could be encouraged to test other models such as monthly price caps.

Dusetzina cast her argument in light of President Joe Biden’s recent unveiling of Moonshot 2.0, which calls for cutting cancer death rates in the United States by 50% over the next 25 years. To do so, Dusetzina writes, patients must be able to afford their drugs.

“Ensuring access to prescription drugs with proven benefits and limiting the amount that patients pay out of pocket would be an important first step,” she concluded. “Without access, even cures are ineffective.”

Reference

Dusetzina S. Your money or your life — the high cost of cancer drugs under Medicare Part D. N Engl J Med. Published online May 4, 2022. DOI: 10.1056/NEJMp2202726

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