Prescription drug coverage under Medicare increased the use of newer, oral-based therapies in patients with myeloma, according to a study published in the Journal of Clinical Oncology — and coverage for drugs via enrollment in a Part D plan (PDP) or through a similar supplemental plan conferred a significant survival benefit for this cohort when compared with Medicare beneficiaries who did not have similar coverage for their medications.1
Enrollment in PDP programs requires monthly premiums, so not all individuals who have Medicare have their prescriptions covered by default. Part D plans, which were launched in 2006, cover oral drugs and medications that that are typically covered at the pharmacy level (in contrast with drugs covered by the medical benefit, which includes parenteral drugs and drugs that require special administration).
The researchers examined records from the SEER-Medicare database and identified 9755 fee-for-service beneficiaries with myeloma from 2006 to 2011. Across this cohort, they looked at who had prescription drug coverage through either a Part D plan or another type of supplemental plan (characterized as other creditable coverage [OCC]) to determine if drug coverage influenced the type of treatment patients received and their resulting health outcomes.
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Patients were determined to have undergone active myeloma care if they received parenteral chemotherapy or had two or more outpatient physician visits during the study period. Across the PDP group, the researchers looked specifically at the use of immunomodulatory drugs (such as lenalidomide or thalidomide) and bortezomib from January 2007 to December 2013.
During the study period, the investigators determined that “treatment of myeloma significantly differed according to the type of prescription drug coverage [the patient had].”1 They found that PDP enrollees were 38% less likely to receive cheaper, classic cytotoxic agents such as vincristine, doxorubicin, cyclophosphamide, carmustine, and inpatient chemotherapy, and were also 14% less likely to be administered parenteral chemotherapy in general. Medicare beneficiaries with supplemental medication coverage were 3% more likely to receive active myeloma care, but did not receive more oral therapies than parenteral drugs when compared to patients without drug coverage.
Overall survival across the myeloma cohort (regardless of coverage type) at 3 years was 43.1%. But this survival was 16% longer in both the PDP and OCC groups. And, patients in both the PDP and OCC groups received more active myeloma care than those without coverage.
“Many physicians do talk to patients about issues related to coverage for oral chemotherapy, and it may come into play during decision-making,” explained study author Adam J. Olszewski, MD, assistant professor of medicine, Alpert Medical School of Brown University, Rhode Island Hospital in Providence. “However, quite commonly physicians either do not know the details of coverage, or are not well-versed in the complexities of Part D coverage and outsource the relevant work to social workers or authorization staff.”
Among individuals with myeloma who had no drug coverage plan in place at diagnosis, 41% obtained either PDP or OCC coverage following a myeloma diagnosis, which impacted the survival benefit observed across the coverage groups as early as the first year after diagnosis. The researchers cautioned that they were unable to definitively determine if the worse survival rates seen in the uncovered group was actually due to lack of coverage or if it was the result of some other phenomena, such as not receiving therapy at all, an inability to access the newer immunomodulatory agents, or because of poor overall control of other medical issues.
While the authors acknowledged that “unobserved clinical differences between beneficiaries with and without prescription drug coverage could have accounted for the differences in mortality,” they also pointed out that patients without medication coverage had fewer comorbidities than individuals in the PDP group.1
Going forward, the study authors expect the issue of access to oral cancer therapies to remain in the spotlight. As a policy brief from the American Society of Clinical Oncology (ASCO) highlights, despite the existence of oral parity laws at the state level, there are no federal policies in place to guarantee that health insurance plans won’t continue to expose patients to cost-sharing requirements for oral cancer therapies that are significantly higher than the cost requirements associated with classic, infusion-based cytotoxic drugs.2
“The main concern about step therapy, as expressed by ASCO and many oncologists, is that cost considerations will dictate the choice of therapy, rather than physician’s opinion and patient’s personalized circumstances…” Dr Olszewski told Cancer Therapy Advisor. “Many older patients will not be able to receive salvage or second-line chemotherapy upon progression, so if they are forced to use cheaper ‘first-step’ therapy and experience worsening of their disease, they might miss out on a chance of accessing more efficacious therapy and die sooner.”
Given the number of patients in the United States who are covered by Medicare and treated for myeloma, the authors concluded that these findings have important implications for both clinicians and health cancer policy. “Providing more equitable access to oral and parenteral chemotherapy options may thus enhance outcomes in myeloma and, hypothetically, other cancers that are treatable with oral targeted agents,” they said.1
Disclosures: Authors of this study disclosed relationships with various pharmaceutical companies. Please refer to the original paper for a complete list of disclosures.
References
- Olszewski AJ, Dusetzina SB, Trivedi AN, Davidoff AJ. Prescription drug coverage and outcomes of myeloma therapy among Medicare beneficiaries [published online August 16, 2018]. J Clin Oncol. doi: 10.1200/JCO.2018.77.8894
- ASCO in Action. Policy issue brief: Parity in coverage for cancer drugs: ensuring access to affordable, evidence-based treatments. https://www.asco.org/advocacy-policy/asco-in-action/policy-issue-brief-parity-coverage-cancer-drugs. Updated November 7, 2017. Accessed August 16, 2018.
