'Unlimited' Cancer Costs Medicare Part D Dilemma

 Learning that a family member has cancer can be devastating enough. Waiting to find out whether a loved one can afford their treatment takes the concern to another level.

That was the case for health policy expert Stacie B. Dusetzina, PhD, when her mother was diagnosed with metastatic breast cancer.

"There is this period where you are waiting to learn more about the cancer type and treatment options, and, of course, what might be covered by your health plan," Dusetzina, an associate professor at Vanderbilt University Medical Center, Nashville, Tennessee, told Medscape Medical News. "Knowing as much as I do about coverage for prescription drugs in Medicare Part D, I was worried we would be in a situation where my mom had to spend over $15,000 out-of-pocket every year for one of these drugs."

That $15,000 would have taken a large chunk of her retirement income and could make treatment unaffordable down the line.

This situation is hardly unique.

Many patients with cancer who rely on Medicare Part D face an impossible choice: "Your money or your life," Dusetzina said.

In a recent perspective in the New England Journal of Medicine, Dusetzina detailed how subtle variations in people's cancer type can have major implications for their out-of-pocket drug costs.

The difference in cost comes down to whether drugs are delivered as pills or infusions. Oral agents are almost always covered under a health plan's pharmacy benefit (Medicare Part D), while physician-administered drugs are covered under the medical benefit (Medicare Part B).

According to Dusetzina, Medicare beneficiaries can face substantial, possibly "unlimited," out-of-pocket costs for drugs covered under Part D if they don't qualify for low-income subsidies. On the other hand, most beneficiaries receiving physician-administered drugs covered under Part B have supplemental coverage, which reduces or eliminates out-of-pocket costs.

Dusetzina broke down the expected first fill and yearly out-of-pocket costs associated with 10 oral cancer drugs covered under Part D. These costs ranged from $3100 to $3392 for a first fill and $10,592 to $14,067 for one year.

In a candid Twitter thread, Dusetzina opened up more about the issues highlighted in her piece: "This paper is about #PartD and Cancer. It is also about #pharmacoequity…This is about how screwed you are if you need cancer treatment and your treatment happens to be covered by #PartD and not #PartB."

"This is ARBITRARY and INEQUITABLE," she added.

What's "arbitrary," Dusetzina explains, is that a rather small, chance distinction in cancer type or subtype can be the difference between affording and not affording treatment, and potentially between life and death.

Take the drug costs for two similar patients with breast cancer.

Patient A has hormone receptor–positive, human epidermal growth factor receptor type 2 (HER2)–negative breast cancer, and thus would likely receive first-line therapy with two oral agents: an aromatase inhibitor and cyclin-dependent kinases 4 and 6 (CDK4/6) inhibitor, most often palbociclib (Ibrance).

For palbociclib alone, out-of-pocket costs would come to $3100 for the first fill and nearly $10,600 over a year for a Part D beneficiary who doesn't qualify for low-income subsidies.

Now take patient B who has HER2–positive metastatic breast cancer. This person would likely receive first-line treatment with trastuzumab (Herceptin), pertuzumab (Perjeta), and a taxane — a combination covered under Part B, which would be subject to an out-of-pocket cap or covered with limited or no cost sharing.

This difference in cancer subtype leaves some patients "paying substantially more for their cancer treatment than others, despite the same goal of extending or improving their lives," Dusetzina writes.

Another arbitrary difference: Who qualifies for low-income subsidies under Part D. A single woman making the current median income, for instance, would not qualify for a Part D subsidy. If she was diagnosed with breast cancer and needed palbociclib, her cost for that drug alone would be nearly half her annual income, and that does not include premiums and other healthcare costs.

The high cost can mean foregoing treatment, stopping treatment early, or reducing spending on necessities such as food and housing. In fact, a recent study from Dusetzina and colleagues showed that for beneficiaries with cancer who do not receive subsidies under Part D, nearly 30% of initial prescriptions for specialty oncology drugs go unfilled.

Fortunately, that wasn't the case for Dusetzina's mother.

"Her cancer subtype is best treated with drugs covered under her medical benefit and she has an out-of-pocket limit on that benefit," she said. "That makes the financial difficulty less of a concern right now."

But with a different subtype, it could have easily gone another way.

On Twitter, Dusetzina called for congressional action: "There is a lot going on now, but @SenateDems & @SenateGOP this needs to be fixed. #Medicare beneficiaries are counting on you to make sure that they can afford the drugs they need. We know that 1 in 3 people in #PartD don't fill their cancer drugs. That is unacceptable."

Dusetzina's work is supported by the Commonwealth Fund. She reported relationships with the Institute for Clinical and Economic Review, the Laura and John Arnold Foundation, Leukemia and Lymphoma Society, National Academy for State Health Policy, and West Health Council, including grant funding/contracts and/or consulting work. She also serves as a commissioner for the Medicare Payment Advisory Commission (MedPAC).

N Engl J Med. Published online May 4, 2022. Perspective

https://www.medscape.com/viewarticle/974754