Out-of-Pocket and Health Care Spending Changes for Patients Using Orally Administered Anticancer Therapy After Adoption of State Parity Laws

Abstract

Importance: Oral anticancer medications are increasingly important but costly treatment options. By early 2017, 43 states and Washington, D.C. had passed laws to ensure privately-insured patients in fully-insured health plans pay no more for orally-administered than infused anticancer medications. Federal legislation is pending. Despite their rapid uptake, the effect of state oral chemotherapy parity laws has not been described. Objective: Estimate changes in oral anticancer medication use, out-of-pocket spending and total health plan spending associated with state adoption of oral chemotherapy parity laws. Design: Observational study using a difference-in-differences approach. Setting: Administrative health plan claims from 2008–2012 for three large nationwide insurers aggregated by the Health Care Cost Institute. Participants: Adults (18–64) living in one of sixteen states passing parity during the study period who received drug treatment for a cancer for which orally-administered treatment options were available (N=63,780). Exposure: Time before and after parity adoption, controlling for whether the patient was in a plan subject to parity (fully-insured) or not (self-funded, exempt via the Employee Retirement Income Security Act). Outcomes: Oral anticancer medication use, out-of-pocket spending, and total health care spending. Results: Oral anticancer medication use increased from 18 to 22% of anticancer medication treatments over time, regardless of parity status (p=0.34). In plans subject to parity, the proportion of fills for orally-administered therapy with no copayment increased from 15% to 53%, more than double that observed in plans not subject to parity (p<0.001). The proportion with out-of-pocket spending >$100/month increased from 8.4% to 11.1%, a larger increase than observed in plans not subject to parity (p=0.004). In plans subject to parity, estimated monthly out-of-pocket spending decreased by $19.44, $32.13 and $10.83 at the 25th, 50th and 75th percentiles of spending (all p<0.001), but increased at the 90th and 95th percentiles by $37.19 and $143.25 (both p<0.001). Parity did not increase six-month total spending overall or for enrollees using anticancer therapy. Conclusions and Relevance: While oral chemotherapy parity laws modestly improved financial protection for many patients without increasing total health care spending, these laws alone may be insufficient to ensure that patients are protected from high out-of-pocket costs.

The impact of state parity laws on copayments for and adherence to oral endocrine therapy for breast cancer

“…Oral endocrine therapies were not included in the aforementioned analysis, but the results of our current study are generally consistent with the finding by Dusetzina et al that parity laws decreased spending for drugs with baseline out‐of‐pocket costs <$50 . Only in states subject to parity laws, median monthly copayments decreased significantly for generic formulations of all 4 drugs after parity legislation, with the greatest decrease for exemestane of >$11.…”

More evidence on the limited impact of state oral oncology parity laws

“…In the current issue of Cancer , Chin and colleagues provide an evaluation of how parity has impacted out‐of‐pocket spending on endocrine therapy for the prevention of breast cancer recurrences, comparing states with and without oral oncology parity laws between 2007 and 2014 . Consistent with prior work, their study indicates that oral oncology parity laws did not consistently reduce out‐of‐pocket spending for endocrine therapy . Indeed, parity reduced spending at the 25th percentile of spending for 2 drugs (anastrozole and exemestane), increased it for a third drug (letrozole), and had no effect on the fourth drug (tamoxifen).…”

“…In response to these challenges, some insurers, such as Blue Cross and Blue Shield of Massachusetts, simply decided to reduce copays to zero dollars . Some plans may choose this approach because the overall budget impact will be relatively small in a small patient population and will garner positive publicity.…”

Patient recommendations for reducing long‐lasting economic burden after breast cancer

“…Although patients consistently suggested expanding what insurers cover, shifting costs back onto insurers may not be enough to reduce economic burden, especially if third‐party payers find other ways to pass costs back to patients. This may happen through increased premiums, deductibles, co‐insurance, cost‐sharing, or tiering medication, as has been done with oral anticancer medications . Subsequently, several states have considered or passed bills that limit patient cost‐sharing, which indicates that even changing insurance has implications for other sectors.…”

“…Subsequently, several states have considered or passed bills that limit patient cost‐sharing, which indicates that even changing insurance has implications for other sectors. Although insurance providers are only one part of the solution to the challenge of economic burden, changes to insurance would require efforts and changes by patients, providers, insurers, state and federal policy‐makers, and the pharmaceutical industry . There may be alternative approaches to minimizing cost and maximizing care, especially when that care occurs outside of the traditional health care setting.…”