Last September, patient advocates finished a day of meetings with their members of Congress in Washington, D.C., by gathering around the Lincoln Memorial Reflecting Pool for the annual Lights of Hope event, during which they lit over 700 luminaries to honor of those who have been affected by cancer.
For the American Cancer Society Cancer Action Network (ACS CAN), organizing the event helps to make cancer a national priority. On February 4, we recognize World Cancer Day and look at the state of the disease. While health care policy reform has improved coverage for cancer patients over the past decade, much work remains, according to a recent ACS-CAN report.
JoAnn Volk, a senior research fellow at Georgetown University and one of the report’s authors, explains how medical management is affecting cancer care and why the healthcare ecosystem must work together to make it simpler, faster and more affordable for cancer patients to get the proper care.
Why are some cancer patients struggling to access proper care?
“For our report, we interviewed patient navigators who help people understand their health insurance. We found that not everything is smooth sailing for people living with cancer. Although the Affordable Care Act (ACA) has limited how much people pay out of pocket, cancer patients still pay plenty and reach that limit quickly.
“On top of those high out-of-pocket costs, patients are also facing medical management from their insurers more often. Oral and cutting-edge cancer therapies are increasingly being subject to tactics such as prior authorization and step therapy. These different tools put hurdles between patients and their doctor’s recommended treatment.”
Each plan has its own utilization management process, different criteria and different paperwork. It could be made uniform and simpler.
Why are newer and oral cancer therapies more likely to be subject to medical management?
“Health plans are singling these therapies out in prior authorization and step therapy policies primarily because of the cost of these treatments and often do not approve newer medications without further justification. There are more restrictions in accessing the high-cost medications regardless of the benefit to the patient. Sometimes the cutting-edge therapies were just not on the insurer’s radar or established within the plan. The insurer often will require a discussion with the prescribing doctor to understand the science behind the medication and why it would work for a particular patient.”
How do these medical management policies affect patients?
“The navigators work with the insurer to address their concerns with the prescribed medications and file an appeal where necessary. While it’s rare that a patient wouldn’t eventually get access to the prescribed therapy, the process of being denied a treatment, filing an appeal and working through the process takes time. For example, the prior authorization process can take from seven to 10 days, but sometimes they can take multiple weeks. It’s stressful for the patient and can affect their care depending on how the treatment was mapped out for them.”
— Celgene Corporation (@Celgene) September 13, 2017
How could policies help to make the process easier for patients?
“Medical management will be something that will be fixed legislatively. The ACA allows plans and insurers to use medical management to decide coverage limitations.
“But one thing that navigators pointed out was that each plan has its own utilization management process, different criteria and different paperwork. It could be made uniform and simpler, regardless of the insurer. Making uniform rules and paperwork for insurers and plans would make things run more smoothly for both doctors and insurers. Health plans with prior authorization and step therapy should have a clear process for appeals, which is something that could be fixed with legislation.”
Is there an opportunity for biopharmaceutical companies to work more closely with insurers to reduce out-of-pocket costs for patients?
“Assistance programs offered by biopharmaceutical companies have already been important tools for patients, according to the navigators we interviewed. But there’s always an opportunity for more partnerships to reduce the financial burden for cancer patients. If manufacturers and insurers work together to address out-of-pocket costs for patients, it would certainly make the process easier for patients and navigators.”
To learn more about policy proposals that can improve patients’ affordable access to effective treatments, read “Innovative Therapies Require Innovative Thinking to Ensure Access and Reduce Financial Burdens on Patients.”