Drugs aren’t the only factor driving costs for patients. Health insurance premium contributions and out-of-pocket costs have added dramatically to the financial burden that patients face.

“In 2003, almost half of patients in employer-provided insurance had no deductible to cover,” the authors of the Leukemia & Lymphoma Society paper wrote. “Ten years later, less than 20% of patients had the same benefit. In fact, as insurers have recognized that increasing deductibles can discourage consumers from accessing their benefits, plans have accelerated this trend. In 2015, the average deductible in an employer-provided insurance plan had increased more than 250% from a decade earlier.”

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Another cause of rising out-of-pocket costs for patients are “price markups” for oncology services at hospitals, according to an analysis of Medicare billing records published in February.6 The authors reviewed records from 3248 hospitals from all 50 states and found that specialty cancer departments charged anywhere from 2.4 to 4.1 times more than what Medicare paid. In some cases, the study’s lead author said, they found markups as high as 15 times the allowable Medicare amount.

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The markups, the authors wrote, most dramatically affect patients who go out-of-network for services. That is a reality more patients face, the study noted, as the trend toward narrower insurance networks reduces the number of available in-network specialists.

The study’s lead author, Martin Makary, MD, MPH, a cancer surgeon and professor of health policy at the Johns Hopkins University School of Medicine in Baltimore, Maryland, said it is an “ethical dilemma” for the nation’s health care providers.

“Is it moral to put a patient into collections or ruin their credit history? For a bill that’s double or triple what their highest payer would pay for the same service? I would argue that’s not right. Especially at a time when patients are at the most vulnerable,” Dr Makary said.

“We have very good people working in a bad system. When you look at the individuals who go into cancer care or even managing cancer facilities or administrating cancer centers, or people who are in the business of medicine, these are good people. They’re working in a system that was never intended to have these consequences.”           


  1. Leading U.S. health systems announce plans to develop a not-for-profit generic drug company [news release]. Intermountain Healthcare: January 18, 2018. https://intermountainhealthcare.org/news/2018/01/leading-us-health-systems-announce-plans-to-develop-a-not-for-profit-generic-drug-company/. Accessed March 2018.
  2. Tefferi A, Kantarjian H, Rajkumar SV, et al. In support of a patient-driven initiative and petition to lower the high price of cancer drugs. Mayo Clin Proc. 2015;90(8):996-1000. doi: 10.1016/j.mayocp.2015.06.001
  3. Solutions for reducing patient cost sharing for medications. The American Journal of Managed Care website. http://www.ajmc.com/journals/evidence-based-oncology/2016/august-2016/solutions-for-reducing-patient-cost-sharing-for-medications. Published August 16, 2016. Accessed March 2018.
  4. Olszewski AJ, Zullo AR, Nering CR, Huynh JP. Use of charity financial assistance for novel oral anticancer agents. J Oncol Pract. 2018 Feb 13. doi: 10.1200/JOP.2017.027896 [Epub ahead of print]
  5. Howard DH, Bach PB, Berndt ER, Conti RM. Pricing in the market for anticancer drugs. J Econ Perspect. 2015;29(1):139-62.
  6. Park A, Xu T, Poku M, Taylor J, Makary MA. Variation in markups on outpatient oncology services in the United States. The American Journal of Managed Care website. http://www.ajmc.com/journals/issue/2018/2018-vol24-n2/variation-in-markups-on-outpatient-oncology-services-in-the-united-states. Published February 17, 2018. Accessed March 2018.