Three new studies on cancer drug costs and prior authorizations highlight barriers to cancer care. To minimize those effects, oncologists should take time to confirm that patients are receiving medications in a timely manner and are not overburdened by the costs of their medication, the authors suggest. The studies were presented at the recent ASCO Quality Care Symposium.
Prior Authorization Slows Receipt of Drugs
In one study, researchers found that roughly three-quarters of oral anti-cancer drug prescriptions require prior authorization from insurance companies and the requirement is associated with a longer interval between the drug prescription date and the date patients receive their drugs (Abstract 6).
To learn how prior authorization impacts access, researchers led by Morgan Lichtenstein, MD, a medical oncology fellow at Columbia NewYork-Presbyterian in New York City, collected information on oral cancer drug prescriptions for adult cancer patients treated at their institution between 2018 and 2019. In total, 1,022 patients were prescribed 1,195 oral anti-cancer drugs.
Among patients who received their drugs, 72.3% required prior authorization. In a multivariable logistic regression analysis, patients with Medicaid were 93% more likely to require prior authorization versus those with Medicare. Compared with patients prescribed oral chemotherapies, those prescribed targeted therapies were more than three times more likely to require prior authorization, and that jumped to more than four-fold for those prescribed hormone therapies.
In addition, a separate multivariable analysis showed that having a prior authorization requirement was associated with a time to receipt of more than seven days versus less than seven days for prescriptions not requiring one. However, having Medicaid was associated with a time to receipt of less than seven days. “This result highlights that the process for obtaining oral anti-cancer drugs is complicated and that there are patient and drug-level characteristics associated with time to receipt,” said Dr. Lichtenstein.
Dr. Lichtenstein added that 13% of prescriptions were never received by patients. “In a separate study, we looked closer at this 13% and saw a variety of reasons for prescription failure,” she said. For example, patients were more likely to receive prescriptions if prior authorizations were issued and if the medications were intended to treat solid tumor types rather than hematologic malignancies.
“Among patients who receive their drugs, we saw a median time to receipt of seven days, but 25% of patients waited more than two weeks for their oral medication, and 5% waited more than 30 days,” she continued. Longer time to receipt of medications was associated with younger age, targeted treatment, and requirement of prior authorization.
Dr. Lichtenstein said that while patients should have equal access to treatments in a timely manner, her work shows that’s not the case. She noted that oncology providers should remain aware that patients can experience significant delays in receiving oral anti-cancer medications.
“We need to follow up diligently to confirm patients receive their medications in a timely manner. At some hospitals, including NYP Columbia, specialty pharmacy implementation has helped take some of the administrative burden off of the medical team,” said Dr. Lichtenstein. “We’ve done additional work looking at the impact of implementing our specialty pharmacy, which showed a higher rate of receipt and trend toward decreased time to receipt after specialty pharmacy implementation. We need to continue exploring ways to expedite this process for our patients.”
An Intervention of Uncertain Value
A second study characterized the out-of-pocket costs of drugs used for cancer-associated anorexia/cachexia syndrome (CACS) and found they varied widely (Abstract 55). The investigators analyzed the average retail price and the lowest price with coupons for each formulation of CACS medications using the most commonly used dosage for a typical fill.
“We found that out-of-pocket costs for just a two-week supply of medications for anorexia/ cachexia ranged from $5 (generic olanzapine or mirtazapine tablets) to $1,156 (brand-name dronabinol solution) and varied widely by formulation of the same drug/dosage: for olanzapine 5 mg, $5 (generic tablet) to $239 (brand-name orally disintegrating tablet),” said lead study author Arjun Gupta, MD, assistant professor at the University of Minnesota in Minneapolis.
Dr. Gupta pointed out that no drugs are approved by the U.S. Food and Drug Administration for CACS, and American Society of Clinical Oncology guidelines suggest it is reasonable to not prescribe a drug for it. “Symptom control drugs can be expensive, and a simple, well-intentioned, seemingly harmless prescription can cause great economic burden to patients. Spending on symptom control can contribute substantially to patients’ financial toxicity given the number of these products used and frequency of use among patients with cancer,” he said.
Dr. Gupta also noted that clinicians may be able to reduce the burden on patients by prescribing less expensive formulations of the same drugs. Or in some cases, the best decision may be not prescribing a drug at all. “Clinicians should reevaluate the risk-benefit ratio of each prescription they write for, no matter how simple, especially in the context of the limited data to support the use of some of these symptom control drugs.”
Cost Increases Impact Survivors
Meanwhile, higher patient cost responsibility may lead cancer survivors not to take drugs as prescribed, according to a retrospective cohort study (Abstract 4). The investigators analyzed information from the Surveillance, Epidemiology, and End Results Program, Medicare claims, and the Consumer Assessment of Healthcare Providers and Systems survey linked data source from 2007 to 2015. Of 11,829 older adult survivors of prostate, breast, colorectal, gynecologic, or lung cancer, 12% reported not following prescriptions exactly due to cost in the prior year. Median cost responsibility in the year before completing the survey was $1,529 for patients reporting that they didn’t take drugs as prescribed and $1,123 for those reporting they did.
The researchers found there was a larger difference in cost responsibility between patients who adhered to their prescriptions and who didn’t in urban areas than in rural areas. Rural patients reported more similar costs regardless of whether they took their medications as prescribed. The survivors who completed the survey were a median seven years out from their cancer diagnoses and had a median age of 76 years.
Lead author Courtney Williams, DrPH, a cancer prevention postdoctoral fellow in the Healthcare Delivery Research Program in the National Cancer Institute’s Division of Cancer Control and Population Sciences, said the results show that cost-related barriers to care for older urban- and rural-dwelling survivors could potentially decrease prescription adherence and result in adverse health outcomes for long-term cancer survivors.
“Oncologists should be able and willing to have conversations about the cost of care with their older patients with a history of cancer, even many years into survivorship,” said Dr. Williams. “Furthermore, lower-costing care does not always equate to value-based or affordable care for patients, especially [for] those with multiple comorbidities or dealing with multilevel resource constraints.”
Dr. Lichtenstein, Dr. Gupta, and Dr. Williams reported no relevant financial disclosures.
