Overview of the Cancer Drug Parity Act
Sarah Hudson-DiSalle, PharmD RPh
The Arthur G. James Cancer Hospital
Cancer treatment is changing at a rapid pace, but the design for insurance coverage of cancer treatment has not changed. Traditionally, intravenous (IV) and injected treatments were the primary methods for delivering chemotherapy. Newer, orally administered chemotherapy medications have become more prominent as treatment choices. Most health plans cover IV therapy through medical benefits and any oral or self-administered medications through retail pharmacy benefits. Although health plans offer affordable copayments for IV therapy, oral chemotherapies are covered at a percentage of the cost. This coverage means that some patients have extremely high costs for their oral medications. As a result, many patients may abandon therapy or choose another treatment that may not be the provider’s first choice.
In an attempt to make these medications affordable to patients, efforts to enact insurance design reform are under way. Legislation that directs health plans to extend coverage for cancer treatments to orally administered anticancer medication at a cost no less favorable than the costs for IV or injected cancer medications has been passed in 47 states and the District of Columbia. However, state laws affect only state-regulated insurance plans, which leaves about 100 million people who have federally regulated insurance in need of parity for their cancer treatment. The Cancer Drug Parity Act of 2017 sought to amend the Public Health Services Act and require group and individual health plans that cover anticancer medications to cover oral medications at a no less favorable cost than the cost for coverage of IV or injected treatments. The bill was introduced to Congress in March 2017 but did not receive the support needed to move it through the legislative process in the 115th Congress.
To increase awareness of the Cancer Drug Parity Act and highlight its importance, this first installment of the “Patient Care Stories” column presents stories submitted anonymously by HOPA members featuring a significant moment in which their work had an impact on patient care.
A patient with ovarian cancer was in a research study that required taking two oral investigational drugs daily. She was suffering from significant, persistent nausea and vomiting as a side effect of the investigational agents and was on the verge of withdrawing from the study because of these side effects. I met with the patient to discuss potential changes to her antinausea medication regimen, seeking medications that would not interact with her investigational drugs. After reviewing the research protocol and determining which antinausea medications did not interact with her investigational drugs, I met with the patient and developed a plan for adjusting her supportive care medications. The primary change was to switch the patient to a granisetron antinausea patch that she could wear continuously and that would require changing only once every 7 days. The patient found that the antinausea patch dramatically improved control of her nausea and vomiting, and as a result she chose to continue with the research study. The patch was very expensive, but I was also able to find a copay assistance program that brought the cost down to an affordable price.
One issue we often deal with as pharmacists is patients’ noncompliance with their medication regimens. As a stem cell transplant pharmacist, I monitor a variety of drug interactions and levels, specifically immunosuppression with tacrolimus and sirolimus. In our ambulatory treatment center, a transplant advanced practice registered nurse sees patients independently, and physician visits are held once a week. As part of the transplant team, I noticed that one patient had persistently fluctuating tacrolimus levels, varying from subtherapeutic to therapeutic to supratherapeutic. I suspected that the patient was taking tacrolimus, posaconazole, and other medications incorrectly. However, in patient interviews, the patient insisted that no medication doses had been missed, so we asked the patient to bring in the pillbox filled with the medications. Following weekly reviews and the pharmacist’s regular filling of the pillbox, the patient was eventually able to demonstrate appropriate filling of the pillbox with more than 20 medications and was appropriately taking them all.
Generally, clinical pharmacists are heavily involved in patient care. Not only are we focused on therapeutic management (ensuring therapy appropriate to the disease and condition and appropriate medication dosing for renal and hepatic impairment), but we are also able to assess patients and evaluate follow-up. We are meticulous in our workups and have the ability to provide education to patients and caregivers. Although we have made great strides to expand clinical pharmacy practice, we still have a long way to go in advocating for the pharmacy profession.
A patient with a germ cell tumor was scheduled to receive chemotherapy with etoposide, vinblastine, and ifosfamide. Unfortunately, his insurance company denied his admission for chemotherapy and approved only an outpatient regimen for him. The patient could not afford a hotel room for 5 nights, so he was going to drive back and forth 1–2 hours from home daily with his wife for outpatient therapy. Given the timing of the chemotherapy and supportive medications, the patient was going to have a chair time of about 11 hours per day. I identified that the main rate-limiting medication for the patient would be the IV mesna that was due at hour 8 after the ifosfamide was started, and I knew that using oral mesna instead would reduce the patient’s chair time by 2 hours. The oral mesna was covered under his insurance for a $0 copay, so I updated the treatment plan to reflect administration of the “patient’s own supply” of oral mesna instead of IV mesna. The patient was able to pick up the prescription for oral mesna and tolerated it without any nausea or vomiting beyond that associated with the underlying chemotherapy regimen. This switch saved time for him and his wife each day as they drove back and forth to the infusion center.
I was processing a refill request for ibrutinib, and while performing an evaluation of the request, I noticed an important drug interaction with the patient’s concomitant medications that could have resulted in increased levels of the ibrutinib. The drug interaction occurred because the patient had been admitted to the hospital for atrial fibrillation. When the patient was prescribed the interacting medication, the problem was not caught by any of the healthcare providers, probably because her oral chemotherapy was withheld during her admission. After identifying the interaction, I communicated the concern to all parties (physicians and coworkers) while working to formulate potential recommendations for alternatives to effectively manage both of the patient’s diagnoses. I consulted with the oncologist to create an action plan until an overall plan could be discussed with a cardiologist. Because the patient was having effective disease control with only a minor, nonserious adverse drug reaction, we determined that the patient should not take the ibrutinib for several days until the overall plan could be formulated. I contacted the patient to explain the situation and make the recommendations and then confirmed a follow-up appointment with the oncologist. After discussion between the cardiologist and oncologist, the interacting medication was changed to an alternative, noninteracting medication, and the patient was able to remain on the effective dose of ibrutinib.
As anticancer regimens become more complex, the role of the clinical pharmacist in managing the side effects of oral chemotherapy, modifying supportive care regimens, performing patient counseling, and facilitating medication procurement will become more crucial. We encourage you to add your voice to support for the Cancer Drug Parity Act by writing to your congressional representative and urging him or her to support this important bill.