Dear Editor:
More than 80% of patients with cancer develop severe pain requiring opioid analgesics, and uncontrolled pain is one of main concerns for patients and their families. Opioids are a highly effective treatment for moderate-to-severe cancer-related pain. Opioids can decrease the intensity of pain, restore function, and improve patients' quality of life, but the choice of drug, dosage, and route needs to be personalized. However, the high cost of some opioids can make it difficult for patients, especially those without appropriate insurance coverage, to receive adequate pain control.
According to a 2013 study by Ramsey et al., patients with cancer are 2.7 times more likely to file for bankruptcy than are individuals without a cancer diagnosis.1 Advanced cancer patients report frequent and severe financial distress.2 Unfortunately, financially distressed patients may skip pain medications and miss doctor's appointments in an attempt to decrease their expenses. These issues are particularly salient with newer opioid formulations and abuse-deterrent formulations that are under patent protection. Often, denial of insurance coverage or high copays cause unnecessary distress for cancer patients and burden them with financial toxicity.3,4
We retrospectively reviewed 143 consecutive test claims for one-month supply of fentanyl patch, oxycodone ER, hydromorphone ER, and oxymorphone EX between February 2015 and March 2016. The claims were based on routine orders made by our palliative care team in the inpatient and outpatient setting. As a comparison, we also evaluated 104 consecutive test claims for one-month supply of morphine ER.
Table 1 shows that 66 patients (46%) who required nonmorphine opioids had high copays or delay in prescriptions due to prior authorization or rejection from insurance. Although only four (3%) of the nonmorphine test claims were immediately rejected, many were likely denied after preauthorization calls, especially if the patient had not tried an opioid on the insurance provider's formulary. This not only affects how rapidly a patient has access to good pain control but also subjects patients to unnecessary trials of medications that can cause side effects.
Table 1.
Opioid Prescription Test Claims
| Drug category | Copay $0–$50 No. (%) | Copay >$50 No. (%) | Preauthorization required No. (%) | Rejected No. (%) | p |
|---|---|---|---|---|---|
| Nonmorphine (N = 143) | 77 (54) | 17 (12) | 45 (31) | 4 (3) | <0.0001 |
| Morphine (N = 104) | 99 (95) | 5 (5) | 0 (0) | 0 (0) |
Insurance copays and other requirements pose a major barrier to the efficient treatment of cancer pain for both patients and physicians. We know that ∼80% of patients with a diagnosis of advanced cancer experience pain as the main symptom of their disease and will require opioid therapy to decrease their distress and suffering. Adequate access to multiple opioid therapies with insurance coverage or low copays is essential to provide adequate symptom control and alleviate the physical, emotional, and financial burdens on our patients Major changes in legislation and regulation of insurance coverage of drugs used to manage cancer pain are needed to prevent unnecessary distress in our patients.
Acknowledgment
MD Anderson Cancer Center Department of Scientific Publications. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
References
- 1. Rhamsey S, Blough DK, Kirchhoff AC, et al. : Washington cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis. Health Aff 2013;32:1143–11522 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Delgado-Guay M, Ferrer J, Rieber AG, et al. : Financial distress and its associations with physical and emotional symptoms and quality of life among advanced cancer patients. Oncologist 2015;20:1092–1098 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Tanco K, Bruera S, Bruera E: Insurance company denial of payment and enforced changes in the type and dose of opioid analgesics for patinet with cáncer pain. Palliat Support Care 2014;12:515–518 [DOI] [PubMed] [Google Scholar]
- 4. Ubel PA, Abernethy Amy P, Yousuf Zafar S: Full disclosure-out of pocket cost as side effects. N Engl J Med 2013;369:1484–1486 [DOI] [PubMed] [Google Scholar]