Impact of the healthcare payment system on patient access to oral anticancer drugs: an illustration from the French and United States contexts

Abstract

BackgroundOral anticancer drugs (OADs) allow treating a growing range of cancers. Despite their convenience, their acceptance by healthcare professionals and patients may be affected by medical, economical and organizational factors. The way the healthcare payment system (HPS) reimburses OADs or finances hospital activities may impact patients’ access to such drugs. We discuss how the HPS in France and USA may generate disincentives to the use of OADs in certain circumstances.DiscussionFrench public and private hospitals are financed by National Health Insurance (NHI) according to the nature and volume of medical services provided annually. Patients receiving intravenous anticancer drugs (IADs) in a hospital setting generate services, while those receiving OADs shift a part of service provision from the hospital to the community. In 2013, two million outpatient IADs sessions were performed, representing a cost of €815 million to the NHI, but positive contribution margin of €86 million to hospitals. Substitution of IADs by OADs mechanically induces a shortfall in hospital income related to hospitalizations. Such economic constraints may partially contribute to making physicians reluctant to prescribe OADs. In the US healthcare system, coverage for OADs is less favorable than coverage for injectable anticancer drugs. In 2006, a Cancer Drug Coverage Parity Act was adopted by several states in order to provide patients with better coverage for OADs. Nonetheless, the complexity of reimbursement systems and multiple reimbursement channels from private insurance represent real economic barriers which may prevent patients with low income being treated with OADs. From an organizational perspective, in both countries the use of OADs generates additional activities related to physician consultations, therapeutic education and healthcare coordination between hospitals and community settings, which are not considered in the funding of hospitals activities so far.SummaryFunding of healthcare services is a critical factor influencing in part the choice of cancer treatments and this is expected to become increasingly important as economic constraints grow. Drug reimbursement systems and hospital financing changes, coupled with other accompanying measures, should contribute to improve equal and safe patient access to appropriate anticancer drugs and improve the management and care pathway of cancer patients.

Patterns of use of oral anticancer treatments in France: a Retrospective Analysis of Cancer Treatments given ORally from 2004 to 2012 (Re-ACTOR study)

“…can influence the decision to prescribe oral versus IV anticancer treatments. Most of these data are not collected in the database [16][17][18][19] . Additionally, to provide robust results and to avoid over-parameterization, a large sample size is required.…”

New oral targeted therapies for metastatic breast cancer disrupt the traditional patients’ management-A healthcare providers’ view

“…In oncology, targeted therapies are increasingly numerous (Kuppens, Breedveld, Beijnen, & Schellens, 2005;Ruddy, Mayer, & Partridge, 2009) and often taken orally (Winer et al, 2009). In addition, the prescription and monitoring of such treatments are time-consuming (Benjamin et al, 2014). Indeed, many obstacles to the dissemination and adoption of innovations exist.…”

“…Besides the fact that they generate a significant load of information to be taken on the medical time, oral targeted therapies are not as successful as they could be, largely because they are not financially profitable enough to hospitals (Benjamin et al, 2014;Hede, 2009 What is more, many structural changes in the health sector have meant that health facilities are often faced with limited financial and human resources. This is complicated by the fact that the funding of structures and available human resources are not adequate for oral treatments because they are focused on a patient physically present in the hospital (Li et al, 2013).…”

“…They most often appear outside of the hospital; community health professionals are therefore increasingly concerned with taking care of these patients (French NCI, 2016). Thus, in France, the emergence of oral treatments taken at home disrupts the traditional organisation of oncology care, meant until then to be primarily dealt with in public and private hospitals (Benjamin, Buthion, Vidal-Trécan, & Briot, 2014). With these treatments, a gradual chronicity (Phillips & Currow, 2010) of certain types of metastatic breast cancer can be detected.…”

“…With these treatments, a gradual chronicity (Phillips & Currow, 2010) of certain types of metastatic breast cancer can be detected. Thus, in France, the emergence of oral treatments taken at home disrupts the traditional organisation of oncology care, meant until then to be primarily dealt with in public and private hospitals (Benjamin, Buthion, Vidal-Trécan, & Briot, 2014).…”