We Should Treat Financial Toxicity With Curative, Rather Than Palliative, Intent

In the companion to this article, Jeong et al¹ present new findings regarding the use of charity assistance among patients beginning treatment with abiraterone acetate or enzalutamide. Their primary findings—one third of patients with prostate cancer require charity assistance to afford these medications—highlight the adverse consequences for patients resulting from the high cost of cancer drugs, particularly those with Medicare Part D as their primary drug benefit. This study provides additional support for calls to reform the Part D benefit structure to improve the affordability of cancer drugs.

Jeong's findings are in line with previous studies that examined cancer drugs more broadly. Specifically, one third of patients required financial assistance to afford their prescriptions,² with approximately 10% obtaining them through manufacturer-sponsored pharmaceutical assistance programs or PAPs.³ This further underscores an ongoing problem: the high cost of cancer drugs makes them unaffordable for many patients, including many who have health insurance.

The Medicare Part D benefit is a particular area of concern. Jeong et al¹ present several findings that suggest that the Part D benefit provides inadequate insurance for patients who require high-cost drugs. First, compared with commercially insured patients, a substantially greater proportion of Medicare patients required financial assistance to fill their prescription for abiraterone or enzalutamide: 22% with commercial insurance vs. 40% with Medicare Part D. Patient out-of-pocket expense was also greater for Medicare patients. Only 7% of commercially insured patients had out-of-pocket costs of $100 US dollars (USD) or more for their first fill, compared with 31% of patients with Medicare Part D. Put another way, although the top 7% of commercially insured patients paid more than $100 USD, the top 7% of Medicare Part D patients paid more than $2,800 USD for their first fill. This disparity in out-of-pocket costs is likely to be the underlying cause of another troubling finding: the disparity in unfilled prescriptions.^4,5 Five percent of patients overall were unable to fill their prescriptions because of cost; uninsured patients aside, this occurred almost exclusively among patients with Medicare Part D. The overall takeaway is clear—for patients who need cancer treatment, Medicare Part D is often inadequate insurance. Even with Part D coverage, some patients are unable to access medications at all and many others are exposed to a large degree of financial toxicity.

On the basis of what we know from previous work, it is a reasonable assumption that this financial burden will result in additional longer-term consequences for Medicare patients. Those who were unable to fill their prescriptions because of cost are at risk for poorer outcomes because of disease or receiving a suboptimal alternative treatment. But even those who fill their initial prescriptions remain at higher risk. Patients who required financial assistance—who were disproportionately Medicare patients—experienced longer time periods before treatment initiation, and delays in cancer treatment are associated with increased mortality.⁶ Patients who face greater out-of-pocket expense are also more likely to experience treatment gaps between refills or to discontinue their cancer therapy altogether.^7,8 These factors may explain the observed association between financial hardship because of cancer treatment and increased risk of mortality.⁹

Pharmaceutical assistance programs—such as those used by the patients studied by Jeong et al¹—are a stopgap measure. Although they do provide access to many patients who would otherwise be unable to afford treatment, they are an unsuitable long-term solution to address financial toxicity because of their opaque eligibility requirements,¹⁰ complex and time-consuming application processes,¹¹ and unreliability. Putting an end to the financial hardship that so many patients with cancer experience will require structural policy changes. Policy solutions that would make substantial strides toward achieving this goal are known and within reach. The Medicare Part D benefit could be restructured both to reduce patient cost sharing in the initial coverage phases and to introduce out-of-pocket maximums.¹² The Medicare Part D Low-Income Subsidy could be expanded. Eligibility for the Low-Income Subsidy currently extends up to only 150% of the federal poverty limit, which translates to $19,140 USD for individuals. A patient with cancer making slightly (or substantially!) more than this threshold would not qualify for subsidy but would still struggle to afford their Part D copays. Increasing the income threshold, potentially with a smoother gradation of benefits, could provide much-needed additional coverage to those at greatest financial risk from cancer treatment.

Importantly, even policy changes such as these would not address the root cause: high drug prices. A variety of strategies to lower drug prices have been proposed. In particular, allowing Medicare to negotiate drug prices has long been identified as a policy change with the potential to drastically lower drug prices for Medicare beneficiaries. However, this idea has not been politically feasible and its future is uncertain.¹² Until we have the political will to seriously address this problem, we will continue to observe what Jeong et al¹ have herein: one third of patients with cancer struggle to afford treatment.

AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

We Should Treat Financial Toxicity With Curative, Rather Than Palliative, Intent

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