Reimbursement and Managed Care News

By Stanton R. Mehr
Published: Monday, Jun 07, 2010
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Reimbursement and Managed Care News

How Much Do Patients With Cancer Pay Out-of-Pocket for Care?

The costs associated with oncologic therapies, particularly biologic agents, can be a stifling burden on patients, as many treatments cost thousands (even tens of thousands of dollars). Even with health insurance, many treatments are on coinsurance tiers, that is, the patient pays a percentage of total cost, unlike fixed copayments for conventional medications. With the influx of “high-deductible health plans,” which are less expensive than insurance offering first-dollar coverage, patients pay up to $5,000 before insurance payments contribute to the cost of care. Researchers from HealthCore in Wilmington, Delaware sought to determine how much patients with commercial insurance pay out-of-pocket when cancer is being treated.

The investigators retrospectively identified oncology claims from a managed care database. Four years of patient records (ending in 2006) were studied. Patients were included in the study if they had at least two medical claims for breast, colorectal, or lung cancer, or non- Hodgkin’s lymphoma. Patient-paid amounts and health plan payments were recorded for each year to detect trends.

A total of 74,630 patients were included in the study cohort. For these patients, health plan payments rose 57% from 2003 to 2006. However, the rise in out-of-pocket costs to the patient was even higher—109%, reaching $5,094 in 2006. Alarmingly, patient out-of-pocket expenses jumped 54% from 2005 to 2006, which may be ascribed to the expansion in high-deductible health plans.

The researchers found that the proportion of biologic drugs was still only 10% of the total costs. The remainder was for medical services, imaging studies, and other care.

Although this study covered a population with health insurance, it is a particularly worrisome trend that patients are paying far more out of their own wallets and purses than they were in the past for oncological care.

Willey VJ, Pollack MF, Lawless GD: Oncology health care and patient out-of-pocket cost trends in a commercially insured population. Presented at the 2008 annual meeting of the American Society of Community Oncology, Chicago, June 3, 2008.

Will Congress Mandate Minimum Hospital Stays for Breast Cancer?

A Congressional hearing in late May made it clear that health plans and insurers should be on their guard: U.S. Representatives don’t like the idea of drive-through breast cancer surgery, and are prepared to detour it.

Although 20 states already have minimum stay bills in place (no less than 48 hours for mastectomies or lumpectomies), breast cancer advocates claim that federal legislation is needed to bring the rest of the states in line. In remarks at the hearing, Representative Frank Pallone (D-NJ) said, “having access to appropriate medical care should not be dependent on the state you live in.” Representative Pallone chairs the important health subcommittee of the Congressional Energy and Commerce Committee.

A representative of the insurance industry’s trade organization, America’s Health Insurance Plans, Susan Pisano, countered that the health plans will cover longer stays, depending on medical necessity. “We do not think that it is a good idea on the state level or the federal level to be putting clinical guidelines into statute," she said.

The proposal, the Breast Cancer Patient Protect Action of 2007 (H.R. 119) has 219 sponsors and bipartisan support. A similar bill in the Senate (S.B. 459) has 19 sponsors at this time. Assuming a consensus conference passes this proposal and it lands on President George Bush’s desk, it is expected that the President will exercise his veto.

Dixon K: U.S. panel mulls minimum breast cancer hospital stay. Reuters May 21, 2008.

Bump in Oncology Costs Is Generally From Increased Utilization of Adjuvant Therapies

The cost to treat cancer has risen significantly, as more tools are at the disposal of clinicians, and more biopharmaceuticals have been approved, generally at higher cost compared with older therapies. The National Cancer Institute, Bethseda, Maryland, has attempted to quantify how these costs have increased over an 11-year period for four different common cancers.

Investigators evaluated 1992–2002 information from the Surveillance, Epidemiology, and End Results database on Medicare beneficiaries for the care of breast, colorectal, lung, and prostate cancer, starting from two months before diagnosis to 12 months postdiagnosis. Data obtained on nearly 307,000 patients revealed that average payments for lung cancer rose to $39,891 by 2002, up 22% after adjusted for inflation from 1991 (Figure). Interestingly, the average payment for initial prostate cancer care actually fell by $196, to a total of $18,261 in 2002.

Inflation-adjusted percent change in the cost of

initial cancer care (1991 - 2002)

Breast Cancer

25 %

Colorectal Cancer

View Conference Coverage
Online CME Activities
TitleExpiration DateCME Credits
Community Practice Connections™: 18th Annual International Lung Cancer Congress®Oct 31, 20181.5
Provider and Caregiver Connection™: Addressing Patient Concerns While Managing Chemotherapy Induced Nausea and VomitingOct 31, 20182.0