Oral Parity: When Modern Medicine Outpaces Policy

Leah Ralph
Director of Health Policy, ACCC

The way we treat patients with cancer is changing, as providers use patient-centered care and targeted therapies, and as oral oncolytics become increasingly prevalent in the marketplace. These innovative, self-administered therapies offer better quality of life for patients who are undergoing chemotherapy, including less travel time, fewer work absences, often fewer side effects, and the convenience and comfort of at-home treatment administration. In addition, for some patients, an oral anticancer medication is their only treatment option.

Inappropriate Coverage for Oral Oncolytics

Yet insurance coverage has not kept pace with medical innovation. Outdated benefit designs continue to cover oral anticancer therapies under the pharmacy benefit and often require high, burdensome out-of-pocket costs through coinsurance. By contrast, traditional intravenous chemotherapy is covered under the plan’s medical benefit, which requires a minimal copay or no cost for the patient.

The financial burden for patients who receive a prescription for an oral anticancer medicine leaves them less likely to adhere to treatment and often unable to fill their prescription. Although many providers use various techniques to aid patients’ adherence to oral therapy, the main reason that patients do not take their medication appropriately is cost. According to a recent study, 10% of patients with cancer do not fill their initial prescriptions for oral anticancer medications as a result of high out-of-pocket costs.1,2

Reimbursement Equity Is Needed

The Association of Community Cancer Centers (ACCC) has been a longtime champion of oral parity, the legislative effort to equalize patient cost-sharing for intravenous and oral chemotherapy drugs. Although advances in oral chemotherapy may provide an easier, less intrusive way to fight various types of cancer, unless Congress and state legislatures act to create reimbursement equity, most patients will not be able to afford to access these drugs.

We have mobilized members to state and federal legislatures, developed educational materials, coordinated fly-ins and letter campaigns, and walked the halls of Congress every year for a federal fix. Because an estimated 25% to 35% of drugs in the oncology drug development pipeline will only be available in pill form, righting inequitable coverage for these therapies should be a financial and moral imperative for legislators and for the oncology community.

States Are Passing Oral Parity Legislation

Forty states have passed oral parity legislation—we have indeed come a long way. These laws do not mandate that oral chemotherapy be covered, but rather they require that if an insurance plan covers chemotherapy, a patient’s out-of-pocket costs must be the same, regardless of how that therapy is administered—orally or intravenously.

As a member of the State Patients Equal Access Coalition, ACCC has partnered with several state oncology societies—including in Virginia, West Virginia, and Arizona in recent years—to pass oral parity laws. This year, we are focusing our efforts on Tennessee and South Carolina.

These laws are critical to the patient–provider shared decision-making process, which enables providers to make decisions based on their medical judgment, and patients can determine what is right for them rather than basing their decision-making on limited treatment options, because anticancer medicines are increasingly cost-prohibitive.

Even as these laws pass, our work is not done. ACCC has been working with coalition partners to create educational materials for the clinical setting; these laws will have minimal impact if patients and providers are not aware of the coverage to which patients with cancer are entitled. We also continue to monitor states as they implement these laws; in some cases, an administrative or legislative fix may be needed.

If you live in a state that has passed oral parity legislation and you believe that your health insurance company is not complying with the law, you should contact your state’s Department of Insurance.

Federal Legislations Still Needed

Although a majority of states have passed state-level legislation, federal legislation is still needed. A federal law would ensure that new cost-sharing restrictions are implemented consistently across the country, and that health plans that fall outside of state regulation, such as those covered under the federal Employee Retirement Income Security Act of 1974 (usually large, multistate health plans), must comply with the same equitable coverage requirements.

In September 2015, an ACCC member spoke at a congressional briefing on the Cancer Drug Coverage Parity Act of 2015, helping to gain critical momentum to move the bill forward.

We were back in Washington in early March for the ACCC’s 42nd Annual Meeting, Cancerscape, and Capitol Hill Day to discuss healthcare for patients with cancer, and to talk with legislators about the importance of the oral parity bill for patients with cancer and for the providers who care for them.

Join Our Efforts

We hope that you will join our efforts and will continue to monitor opportunities to weigh in with your state and federal legislators. If you would like to join our advocacy efforts, please contact me at This email address is being protected from spambots. You need JavaScript enabled to view it..

References

  1. Raborn ML, Pelletier EM, Smith DB, Reyes CM. Patient out-of-pocket payments for oral oncolytics: results from a 2009 US claims data analysis. J Oncol Pract. 2012;8(3 suppl):9s-15s.
  2. Raborn ML, Pelletier EM, Smith DB, Reyes CM. Patient out-of-pocket payments for oral oncolytics: results from a 2009 US claims data analysis. Am J Manag Care. 2012;18(5 spec no 2):SP57-SP64.

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