Time for Congress to Fix Discriminatory Chemotherapy Payment Policy for Patients

Given the statistics, each of us knows someone whose life has been touched by cancer. This year, an estimated 1.6 million Americans will be diagnosed with cancer. While many advanced and potentially life-saving treatments for cancer exist, unfortunately, many of them often are out-of-reach for patients due to cost discrimination and unreasonable insurance payment policies. Yet, if a group of strange bedfellows in Congress is successful, people with cancer across the country will have equal access to chemotherapy treatment whether it is provided in physicians’ offices, outpatient clinics, or self-administered in their homes.

Historically, most cancer drugs prescribed to patients were administered in a physician’s office or outpatient client, via a port or intravenously (IV) – treatment sessions that can take hours or days at time. For this type of care, patients are typically charged a standard co-payment for a visit to their physician’s office or an outpatient clinic. However, as more self-administered drugs, including orally administered and self-injecting drugs, become available, patients are instead charged drug or pharmacy co-payments. Co-payments for these self-administered drugs – often just a different formulation than the drug administered via IV – can be prohibitively expensive, costing patients thousands of dollars a month. Ironically, for patients with these insurance policies, it is less expensive, but more burdensome, for them to get care in a physician’s office or clinic rather than receiving treatment at home.

Patients who rely on self-injectables or oral chemotherapy pills can find themselves spending thousands a year on out-of-pocket costs because they receive the drugs from a pharmacy rather than in their doctor’s office. Yet, being able to take self-administered treatments helps patients maintain their regular work and family schedules. These treatments also allow them to continue working – rather than being gone for hours or days at a time to receive in-office chemotherapy infusions – and often prove to be less stressful and more efficacious because the home treatment regimen is less burdensome with respect to time and logistics.

Particularly for patients in rural or underserved communities, being able to receive treatment at home is preferred over driving significant distances and sometimes staying overnight to receive care in another community. Patients are being charged a premium for these advantages. People with cancer should not have to pay more for a treatment modality that allows them to remain close to their families, while remaining contributing members of society.

All people with cancer deserve access to the anti-cancer regimens recommended by their physicians and should not face discriminatory financial policies based on treatment modality. The disparity in payment policy adversely impacts patients and families – economically and logistically – forcing many patients to choose an infusion-based treatment regimen because they cannot afford the out-of-pocket pharmacy expenses associated with an oral or self-injectable at-home option.

Fortunately, state legislators in 40 states and the District of Columbia have recognized the patent unfairness of these policies and have enacted laws to help ensure access to oral chemotherapy for those patients for whom their physicians determine it is appropriate. However, due to state and federal jurisdictional issues, those laws do not apply to patients who are covered under self-insured group plans (an estimated 1/3 of people nationwide) and people in the remaining 10 states also need protection. As such, federal policymakers – Reps. Leonard Lance (R-N.J.-7th District) and Brian Higgins (D-N.Y.-26th District) and Sens. Mark Kirk (R-Ill.) and Al Franken (D-Minn.) have joined together in a bipartisan alliance to introduce the Cancer Drug Coverage Parity Act of 2015 (H.R. 2739/S. 1566), which, if enacted, would require out-of-pocket payment parity for all types of anticancer drugs, irrespective of the formulation. The bill only applies to those commercial insurance plans that already cover chemotherapy; it does not require coverage for chemotherapy if a plan does not currently provide it.

Upon the bill’s introduction, Meghan Buzby, senior director of advocacy for the International Myeloma Foundation, said, “For patients living with cancer across the country, this bill will mean one less thing to worry about. They will no longer have to decide between the best treatment and financial stability, and can focus on what really matters: beating their cancer.” The IMF leads the Patients Equal Access Coalition, an advocacy organization of patients, health care professionals, care centers, and industry working together to ensure affordable access to all treatment options for people with cancer.

In this era of partisanship, particularly within health care policy, it is quite telling that the Cancer Drug Coverage Parity Act of 2015 has broad bipartisan support and is being led by an atypical pairing of Democrats and Republicans. Cancer does not discriminate, and therefore, our nation’s cancer treatment payment policies should not discriminate, either. Congress should pass the Cancer Drug Coverage Parity Act of 2015.

Ilisa Halpern Paul is President of the District Policy Group, a boutique health policy and government relations consulting practice within Drinker Biddle & Reath, LLP.  The views expressed are the author’s own. Carolyn Hull contributed to this column.

Morning Consult