Why individual‐level interventions are not enough: Systems‐level determinants of oral anticancer medication adherence

Abstract

Nonadherence to oral anticancer medications (OAMs) in the United States is as low as 33% for some cancers. The reasons for nonadherence to these lifesaving medications are multifactorial, yet the majority of studies focus on patient‐level factors influencing uptake and adherence. Individually based interventions to increase patient adherence have not been effective, and this warrants attention to factors at the payor, pharmaceutical, and clinical systems levels. Based on the authors' research and clinical experiences, this commentary brings fresh attention to the long‐standing issue of OAM nonadherence, a growing quality‐of‐care issue, from a systems perspective. In this commentary, the key driving factors in pharmaceutical and payor systems (state and federal laws, payor/insurance companies, and pharmaceutical companies), clinical systems (hospitals and providers), and patient contexts that have trickle‐down effects on patient adherence to OAMs are outlined. In the end, the authors' recommendations include examining the influence of laws governing OAM drug pricing, OAM supply, and provider reimbursement; reducing the need for prior authorization of long‐approved OAMs; identifying cost‐effective ways for providers to monitor nonadherence; examining issues of provider bias in OAM prescriptions; and further elucidating in which contexts patients are likely to be able to adhere. These recommendations offer a starting point for an examination of the chain of systems influencing patient adherence and may help to finally resolve persistently high levels of OAM nonadherence.

Addressing cost‐related nonadherence to oral anticancer medications through health policy reform: Challenges and opportunities

“…In prior work, we found that parity laws had relatively small effects on out-of-pocket spending overall, but may have benefited some patients with very high out-of-pocket spending on OAMs. 14,15 However, parity is a benefit for individuals enrolled in fully-insured plans and excludes approximately half of the commercially insured (those in self-funded plans-presumably the "loophole" mentioned by Dean et al) 2 , as well as the largest group of anticancer medication users-Medicare Part D beneficiaries. Although federal proposals would expand parity to self-funded plans and to states that have not yet passed these laws, additional efforts would be needed to ensure that Medicare beneficiaries (particularly those covered by Part D) have sufficient out-of-pocket protections for their anticancer treatments.…”

“…Dean et al 2 recommend multiple cost‐reduction strategies that target state and federal policies and various actors across the pharmaceutical supply chain. Specifically, the authors call for increasing generic utilization, “closing the loopholes” in oral chemotherapy parity laws, sharing rebates with patients at the point of sale, and addressing the appropriateness of high‐cost medications when lower cost treatments are available.…”

“…In the current issue of Cancer, Dean et al 2 discuss the payer, pharmaceutical, and clinical-system drivers of OAM nonadherence and propose recommendations aimed at decreasing patients' out-of-pocket burden, increasing OAM price and coverage transparency, and improving patient management and monitoring-strategies that largely mirror those in the 2018 National Academy of Medicine report Making Medicines Affordable: A National Imperative. 3 In this editorial, we discuss several of Dean et al's proposed interventions aimed at payers and the pharmaceutical supply chain 2 and highlight the challenges and opportunities for improving patient access to OAMs through system reform. We focus on payers and the pharmaceutical supply chain because these systems set prices and reimbursement in the United States and are directly responsible for cost-related barriers that influence the accessibility and affordability of prescription medications.…”

“…However, OAMs are expensive and often require substantial out‐of‐pocket spending by patients, even those with insurance, which contributes to suboptimal uptake and adherence. In the current issue of Cancer , Dean et al 2 discuss the payer, pharmaceutical, and clinical‐system drivers of OAM nonadherence and propose recommendations aimed at decreasing patients' out‐of‐pocket burden, increasing OAM price and coverage transparency, and improving patient management and monitoring—strategies that largely mirror those in the 2018 National Academy of Medicine report Making Medicines Affordable: A National Imperative 3…”

“…In this editorial, we discuss several of Dean et al's proposed interventions aimed at payers and the pharmaceutical supply chain 2 and highlight the challenges and opportunities for improving patient access to OAMs through system reform. We focus on payers and the pharmaceutical supply chain because these systems set prices and reimbursement in the United States and are directly responsible for cost‐related barriers that influence the accessibility and affordability of prescription medications.…”