by Amanda Conschafter, blog editor
This month advocates, patients and their families reflect on the toll cancer takes, the progress that new treatment options offer and the obstacles that too many patients still face. That’s because September marks national Blood Cancer Awareness Month, Ovarian Cancer Awareness Month and Prostate Cancer Awareness Month. And while these diseases vary, those who suffer from them continue to face at least one common challenge: hefty cost-sharing that prices some patients out of care.
Though the gravity of cancer once virtually guaranteed patients coverage for life-saving medicines, insurers have shifted their approach in recent decades. The Affordable Care Act made some progress in ensuring cancer patients’ access to treatment by disallowing coverage denials based on pre-existing conditions. The legislation also eliminated health plans’ lifetime and annual caps on spending for essential health benefits.
As President Barack Obama explains in his August 31 presidential proclamation declaring Prostate Cancer Awareness Month, “Cancer should not be a death sentence, nor should it condemn individuals to a life of poverty just because they do not have access to the quality, affordable care they need.” Yet the Affordable Care Act’s measures have not eliminated this experience for cancer patients.
Instead, many insurers have turned to specialty tier structures for prescription drugs, placing cancer drugs in the highest tier–which requires the highest cost-sharing by patients. Co-insurance for cancer medications can be between 25 and 33 percent, making treatment costs prohibitive. Some exchange plans have even been accused of discrimination for their benefit design, which some argue is meant to dissuade cancer patients from signing up.
New attempts to define and pursue “value” in cancer treatment present still more challenges for cancer patients. First, the Center for Medicare and Medicaid Innovation introduced the Oncology Care Model earlier this year. Physicians and patient advocates have expressed concerns that the model could discourage physicians from prescribing patients breakthrough drugs because the model prioritizes and incentivizes cost savings.
Second, the American Society of Clinical Oncology introduced its value framework, which seeks to guide physicians and patients’ treatment decisions by analyzing a medication’s cost, toxicity and benefit as demonstrated in clinical trials. The suggested framework has also raised questions about allowing for access to breakthrough treatments and incorporating the individual values and experiences of each patient.
Awareness months excel at highlighting the need for prevention, screening, research, and patient support communities. They may do well to also ask policymakers and the public to consider one more pivotal issue: As screening aids in more early detection and advanced research produces cutting-edge treatments, can patients access the medications that can save them?