Cary Presant, MD
Oral parity legislation for getting newer drugs to patients under similar coverage terms as for older drugs often involves a battle that doesn’t stop when a law is passed. Forty states have now enacted some kind of costlimiting legislation, four states are holding out, and the remainder have legislation in the works.1
A number of these deals involve compromises that soften the financial impact for payers, and not enough is being done to educate doctors and patients about the benefits these programs do allow, physicians and advocates say. They say an important part of the safety net aspect of these laws has to be education that lets patients know they have another option for lessening the cost of cancer care.
Table: Higher Out-of-Pocket Costs Lead to Nonadherence
Source: Streeter SB, Schwartzberg L, Husai N, Johnsrud M. Patient and plan characteristics affecting abandonment of oral oncolytic prescription. J Oncol Pract. 2011;7(suppl 3):46s-51s. doi: 10.1200/JOP.2011.000316.
A case in point is AB 219, an oral drug law enacted in California in early 2015 that underwent a rocky road to passage in a form that was different from what its proponents had envisioned. In the end, two advocacy groups dropped their support because they didn’t think the law was going to do an adequate job of improving access to care for patients with cancer. The bill originated as a desire for a “pure parity” law that would force payers to cover oral anticancer medications on the same cost basis as they would for intravenous or injected chemotherapy, but the legislation was buffeted by opposition and vetoed by former Gov. Arnold Schwarzenegger before being modified into a caps bill that simply limited patient co-payments and coinsurance expense to $200 per medication, per month, after deductibles were met.
One of the triggers for this less favorable adjustment, explained Meghan Buzby, senior director of advocacy for the International Myeloma Foundation (IMF), was first the adoption of a $100 cap bill in Louisiana and later a $300 cap bill passed in Utah. Advocates began to worry that opponents of the California bill would notice what was happening elsewhere and decide to push hard for similar legislation. “We knew that Utah would potentially affect the California bill. And in fact it did. They brought up caps as opposed to pure parity,” Buzby said.
This caused certain sponsors to back out. Buzby explained that a $100 cap might have been acceptable to patient advocates but that $200 was statistically too far out of the comfort zone (Table, Cover). Too many patients would find that amount above their ceiling of affordability and balk at paying, thereby foregoing treatment and missing out on the opportunity to bring their cancer under control. The National Patient Advocacy Foundation went against the bill, and so did the IMF. “We do not support caps bills that go over $100,” Buzby said, citing an Avalere study showing declining adherence among patients the more they pay out-of-pocket.
Although it’s still important to the IMF and other groups that patients in California have affordable access to cancer medications, there is no reliable tracking system for following up and finding out whether payers are, in fact, adhering to the new caps law. Patients from other states with laws intended to equalize intravenous (IV) and oral drug costs have notified the IMF that there are issues of noncompliance in those localities, whereas California has registered only one complaint about noncompliance with AB 219, according to the Department of Managed Health Care. The Association of Northern California Oncologists has attempted to find out how well the law is performing but did not get very far, according to group Executive Director Jose Luis Gonzalez: “In late 2015, we attempted to survey the members on the implementation of AB 219 in light of some reports that some health plans were not in compliance. No members responded to that survey,” he stated in an e-mail response.
Cary Presant, MD, chairman of the board of the Medical Oncology Association of Southern California and the author of Surviving American Medicine, said that although laws like AB 219 may not be everything advocates desire, they represent an important element of the access network for patients. He said an education program that encompasses both physicians and patients is key to making certain that people know that such options are available to them.