By Amanda Conschafter, blog editor
Once upon a time, the gravity of cancer ensured its patients access to life-saving treatments. But in the Institute for Patient Access’ new white paper, “Protecting Cancer Care: Improving Transparency and Patient Access,” oncologists argue that budget-conscious insurance methods now put cancer care at risk. The authors, members of AfPA’s Oncology Therapy Access Physicians Working Group, express particular concern about specialty tier structures, prolonged prior authorization processes and lack of parity among care options. They suggest that greater transparency would mark a significant step toward ensuring optimal cancer care.
But at present, many insurers disrupt care by placing vital therapies within specialty tiers, attached with often exorbitant co-pay requirements. As a result, many cancer patients are effectively priced out of treatment. In the IfPA white paper, oncologist
Nadim Nimeh, M.D. describes a patient’s experience, saying “One of my patients was a professional whose cancer was not improving with treatment. I just couldn’t figure out why. After we lost him, I found out that he had not taken his high-cost medicine because he didn’t want to bankrupt his family.”
Prior authorization can also present a threat to effective treatment. As the white paper explains, patients with immediate medical needs cannot always abide lengthy approval periods. Several states have passed legislation requiring standard and electronic prior authorization forms, to which insurers must respond within 24 hours.
Legislation has also played in a role in addressing parity, another issue explored by the white paper. While 33 states and the District of Columbia have passed legislation requiring equal insurance coverage for oral and infused cancer therapies, patients in some states still face discrepancies in payment policies. The paper also notes disparate coverage based on the treatment site, stemming partly from the federal 340 B program. Misuse of the 340 B program, the white paper warns, could result in local community care centers’ closing. And that could complicate access to care for elderly patients, who often depend upon others to drive them to medical appointments.
Better access, working group members contend, begins with clear insurance policies that specify out-of-pocket costs, provider networks, drug formularies and fees for diagnostic procedures. Patients also should know if their physicians employ clinical pathways, whereby physicians may be financially rewarded for using certain treatments in a specific order.