Managing the Financial Fallout of Cancer Care

Cancer care is more exact-and more expensive-than ever. Targeted therapies at the molecular and immunologic levels are increasingly effective and less toxic than cancer treatments of the past, but the cost can be crippling.

According to a new paper in the Annals of Translational Medicine, $115.4 billion was spent on personal healthcare-related to cancer in 2013, and that number is projected to exceed $200 billion by 2020. Fueled by the expense of therapies, drug prices inflated by manufacturing costs, market pressure, and the high cost of research and development, this growing expense has increasingly rested on the shoulders of cancer patients.

According to the report, as the toxicity of treatments declines, a new “financial toxicity” is emerging in the form of higher deductibles, co-insurance, copayments, and out-of-pocket expenses for patients. In addition to patients having decreased productivity at work due to illness, or perhaps even having to stop work, out-of-pocket costs can exceed 20% of a patient’s income and even push them into bankruptcy.

“As cancer drugs become more effective, patients receive them for longer. With increased cost sharing, patients are then responsible for a growing portion of drug costs. Over time, these out-of-pocket costs from rising deductibles, copays, co-insurance, and premiums can add up for some patients to insurmountable debt,” says S. Yousef Zafar, MD, a researcher and medical oncologist at the Duke University School of Medicine and co-author of the paper. “Our studies have suggested that insured patients receiving cancer treatment cut out vacations, spend less on food and clothing, and spend down savings all to help pay for their care.”

Treatment prices are one part of the problem. Before 2000, the average annual price of cancer treatment was $5,000 to $10,000. Now, some medications cost more than $10,000 per month, with the median price of the 13 cancer drugs approved by the FDA as of 2015 reaching $145,000 per year. Biologic and targeted therapies are to blame, despite their physiological benefits to patients. Two such medications alone-added to the chemotherapy cocktail for metastatic colon cancer-raised the tab for six months of treatment by about 285%, according to the report.

These costs force some patients to stop treatment altogether. The paper notes that 70% of Medicare Part D patients taking at least one of the top five oral cancer drugs stopped treatment in 2008 due to high out-of-pocket costs. Out-of-pocket costs greater than $500 is associated with a 25% rate of abandonment for oral therapy compared with a 6% abandonment rate for costs under $100, the paper notes.

Related:Bringing Value to Cancer Care

Making changes to the way drugs are priced is one way forward, the paper notes, suggesting that allowing Medicare to negotiate drug pricing could save $40 to $80 billion per year. There are also suggestions to mandate Medicare cover all medications approved by the FDA and to get rid of incentives that reward physicians for prescribing more expensive drugs. The paper also suggests that payment model changes is an idea that is gaining traction, with movement being made toward a pay-for-performance model that would reward physicians based on the effectiveness of treatments. Value-based insurance designs have also been proposed, which encourage the use of high value-services by providing more cost support, with lower value services having a greater cost-sharing.

“This design was meant to encourage patients to pursue therapies that had high-level evidence of clinical effectiveness and to reduce the overall barriers to high value medical services through supplemental benefits or reduced cost-sharing options,” the paper notes. “Evidence shows that reduction of out-of-pocket costs through value-based insurance design programs improves medication adherence by 2.7% to 3.4%.”

More to be done

There has been some movement toward making cancer care more affordable, Zafar says, but there is much more work to be done.

“Health systems and payers are, in some fashion, making a shift toward value-based reimbursement for primary and specialty care may help,” he says. “For cancer care specifically, this might take the form of evidence-based clinical pathways that reduce drug-related costs, or care coordination and access to oncology acute care, both designed to reduce ED visits and avoidable admissions. Innovative insurance design should reward clinicians for building these aspects of care into their health systems.”

Solutions will likely be a combination of several strategies mentioned in the paper, he adds.

“Ultimately, we need to see a reversal of the current drug pricing trend. In the meantime, payers should consider decreasing cost-sharing for high-value interventions that can improve patient outcome,” Zafar says. “Health systems should increase cost transparency for patients so that patients don’t receive surprise bills months after treatment. And clinicians should be proactive in addressing the cost of care with patients. As an oncologist, I rarely have any idea how much a particular intervention will cost my patient, but if I know my patient is having trouble affording care, I can refer them to a pharmacist, financial counselor, or social worker who can get them to the right resources.” 

Rachael Zimlich, RN, BSN, is a writer in Columbia Station, Ohio.