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CONNEXION HEALTHCARE BLOG
Cancer Care Reimbursement: A Barrier to Quality of Life
Posted 03/30/2010
A new generation of oral cancer chemotherapies has emerged in the past five years and transformed
cancer treatment for many patients. Because they are noninvasive and widely regarded as convenient,
oral treatments are an appealing alternative to traditional intravenous (IV) therapy for many. However, for
many others, the costs of these drugs are totally out of reach due to current insurance reimbursement
policies.
Cost of oral chemotherapy drugs (for which estimates range from approximately $25,000 to more than
$75,000 per year*) should not be a barrier to an individual’s preferred treatment method—and would not
be if coverage were structured the same way it is for IV therapy.
Reimbursement Disparity
In the United States, there is a large discrepancy between how much cancer patients must pay out-ofpocket toward the cost of IV versus oral treatment. The reason for the difference is that oral
chemotherapy is generally covered under a prescription benefit, which tends to have higher copays than
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a medical benefit. IV therapy, however, is considered a medical benefit because it is provided in a
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hospital or a physician’s office. Therefore, IV treatment involves minimal out-of-pocket costs for an
individual while oral therapy can cost thousands of dollars.
IV Vs. Oral Drug Costs
It is difficult to provide an accurate, "apples-to-apples" comparison of IV and oral
chemotherapy costs due to variables such as type of cancer, side effects, treatment setting,
and geographic location. However, some have speculated that oral therapy is less expensive
overall, mainly because it doesn’t include additional costs associated with IV therapy, such as
hospital, clinic, or office procedure fees; equipment fees; and professional staff administration
fees.2
One Oregon man’s story highlights the inequities of insurance coverage as it currently exists in most
states. Chuck Stauffer received a diagnosis of a malignant brain tumor in 2005. After undergoing
neurosurgery, Mr. Stauffer received chemotherapy treatment for two years. Because he chose oral
therapy as his treatment option, he was faced with having to pay $5,500 for the first 42-day supply and
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$1,700 per month after that.
Had Mr. Stauffer chosen IV treatment, his financial responsibility would have been greatly reduced.
However, he and his family believed that oral treatment would be better tolerated, and he would not have
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to endure frequent trips to a clinic to be connected to an IV line for hours.
Medicare reimbursement policy further underscores the problem of inequitable chemotherapy coverage.
In what are often confusing guidelines, Medicare also covers oral therapy as a prescription benefit
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through its "Part D" component. This seemingly unfair system is imposed on the segment of the
population that may need cancer treatment the most—and that may also benefit the most from an oral
regimen.
The financial burdens imposed by private and public insurers make it impossible for many cancer patients
to afford their preferred cancer-treatment method, thus creating a barrier to oral therapy as an option—
even though many oral therapies do not have an IV equivalent. As a result, many patients and their
physicians are denied an important alternative to making cancer a manageable chronic condition.
Reimbursement Parity: Progress in Some States
In 2007, as a result of lobbying efforts by Mr. Stauffer’s family, private insurers, and the American Cancer
Society, Oregon became the first state to pass a law requiring insurers to provide equivalent
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reimbursement for oral and IV chemotherapy drugs. Specifically, the law states, "A health benefit plan
that provides coverage for cancer chemotherapy treatment must provide coverage for a prescribed, orally
administered anticancer medication used to kill or slow the growth of cancerous cells on a basis no less
favorable than intravenously administered or injected cancer medications that are covered as medical
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benefits."
Oral Therapy Is Not Perfect
Oral chemotherapy is not without some drawbacks. There are issues associated with safety, such as
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potential prescription errors and drug interactions, as well as issues related to patient adherence. For
example, some patients often fail to comply with the prescribed treatment, sometimes taking too many or
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too few pills—because of factors such as cost, forgetfulness, or complicated regimens. In addition,
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similar to IV treatment, some patients may experience severe side effects.
However, for treatment-appropriate patients, the benefits of oral chemotherapy can far outweigh any
potential problems, and these patients should not be prevented from choosing oral therapy based solely
on cost barriers.
Oral Chemotherapy—The Wave of the Future
According to the National Comprehensive Cancer Network, one-fourth of cancer drugs now in the pipeline
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are planned as oral drugs. We can only hope that other states follow Oregon’s lead and pass similar
parity legislation so that reimbursement policy will catch up—and keep up—with the current and emerging
oral therapies.
Financial considerations should not have to be an issue for patients struggling to beat cancer. Patients
should have the right to avail themselves of a treatment method they can self-administer in the comfort of
their homes—one that frees them of hours attached to an IV and contributes to a greater sense of control
and normalcy, to the extent possible, throughout their treatment process.
Oral chemotherapy is bringing us closer to regarding and treating many cancers as manageable, chronic
conditions—which is an incredible step in terms of how it may positively affect a cancer patient’s mindset,
let alone recovery.
References
1. Nelson R. Oral chemotherapy poses financial burden to patients. Medscape Medical News Web
site. Published May 7, 2009. Accessed March 18, 2010.
2.
National Comprehensive Cancer Network (NCCN). NCCN Task Force Report. NCCN Web site.
Published 2008. Accessed March 18, 2010.
3.
Pollack A. As pills treat cancer, insurance lags behind. The New York Times. The New York
Times Web site. Published April 15, 2009. Accessed March 18, 2010.
4.
Kirk HS. Orally administered chemotherapy: an Oregon family’s story. Presentation to: Council of
State Governments; December 11, 2009.
5.
Hede K. Increase in oral cancer drugs raises thorny issues for oncology practices. J Natl Cancer
Inst. 2009:101(22):1534-1536.
6.
Leveling the playing field. Oncol Issues. Association of Community Cancer Centers Web site.
Published May/June 2009. Accessed March 18, 2010.