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problems in terms of medication pricing and insurance , but oral parity is a patientoriented , short-term fix that is simply asking why we are ‘ picking on ’ oral and self-injected drugs to make them unaffordable ,” Dr . Rosmarin added .
As a member of the Coalition to Improve Access to Cancer Care ( CIACC ), ASH is working with organizations such as LLS to actively advocate for the Cancer Drug Parity Act to ensure people with cancer have equality of access ( and equality of insurance coverage ) for all approved anti-cancer regimens . ASH also has supported legislative efforts at the state level and continues to work with stakeholders and advocacy groups to support ongoing efforts in a number of states that still lack legislation .
For many years , ASH and other organizations have been lobbying on Capitol Hill to encourage the passage of federal oral-parity law . Visit hematology . org / advocacy for fact sheets , talking points , tips for contacting elected officials , and more information about the need for oral parity .
Do Parity Laws Work ?
Data on the effectiveness of oral-parity laws are limited , but what has been published supports the claim that legislative efforts are , at best , only a partial solution . A study published last November by Dr . Dusetzina and colleagues showed only “ modest ” improvement in financial protection for patients in states with parity laws on the books . 3
“ We found really mixed results for the effectiveness of parity legislation ,” Dr . Dusetzina said . “ For most people it decreased OOP spending , but strangely it increased spending for those with the higher costsharing levels .”
In states that implemented oral-parity laws , prescriptions for OAMs with $ 0 copayments increased from 15 to 53 percent , which was more than double the increase in plans not subject to parity ( 12.3 % to 18.0 %; p < 0.001 ). At the same time , though , the proportion of patients
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with OOP spending higher than $ 100 per month increased from 8.4 to 11.1 percent , compared with a slight decline in plans not subject to parity ( p = 0.004 ).
She added that this was the first large study on the topic that included information on plan-funding types , which allowed researchers to differentiate between plans that had to comply with state parity laws and those that didn ’ t .
“ ... Oral parity is a patient-oriented , short-term fix that is simply asking why we are ‘ picking on ’ oral and selfinjected drugs to make them unaffordable .” — ALAN ROSMARIN , MD
Dr . Dusetzina , who was at the University of North Carolina at Chapel Hill when she published this research , suggested higher deductible spending could explain this unexpected finding . “ We think that the proportion of people on private insurance plans that have large deductibles has gone up ,” she said .
Along with parity laws , the authors argued that U . S . insurers need more direct controls on cost-sharing . “ It ’ s not just making prescription-drug benefits equal to medical benefits , but also thinking about putting some more formal limits on OOP spending , like a cap per pill , that
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really limit the total amount of financial exposure a person would have when they fill their prescription ,” she suggested .
“ Dr . Dusetzina ’ s data raise questions about the other methods that insurers can use to shift costs onto patients . For example , high-deductible health plans are preventing patients from fully benefitting from parity laws ,” Ms . Lee commented .
“ The state legislations can only extend so far , and then we look to the federal government to pick up the mantle and carry it further ,” she added . ( See SIDEBAR 2 for another side effect of patient-administered therapies : waste .)
“ It ’ s the Prices , Stupid ”
Oral parity does have its limitations . For one , the legislation would only make OAMs as expensive as intravenous chemotherapies .
“ If you peel the issue back to its base , we have absurd drug prices in the United States ,” Dr . Rosmarin said , “ and the prices for oral anti-cancer drugs are nothing compared to the next generation of drugs that are coming our way , like chimeric antigen receptor T cells and other immunebased therapies .”
In his well-known paper explaining why health-care costs are so high in the U . S . compared with other developed countries , the late Princeton health economist Uwe Reinhardt , PhD , and authors bluntly suggested , “ It ’ s the prices , stupid .” 5 Indeed , some researchers and clinicians suggest that the real answer to oral parity lies in lower oncology drug prices overall . Any other efforts are just serving to shift the burden of costs to insurers , who will ultimately pass along those costs to policyholders in the form of increased premiums . 6
America ’ s Health Insurance Plans ( AHIP ), a political advocacy and trade association with about 1,300 membercompanies that sell health insurance to more than 200 million Americans , is in full agreement with this theory .
“ We need to find ways to bring the everincreasing prices of prescriptions under control ,” said Cathryn Donaldson , AHIP ’ s
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director of communications . “ Health plans are committed to ensuring that patients have access to medications that are safe , effective , and affordable . However , oral-parity legislation would place an arbitrary limit on cost-sharing between medical and pharmacy benefits , forcing premiums to increase for all consumers as a result – not just those who would use oral chemotherapy .”
This position , at least so far , seems to have little support . Ms . Lee noted that in the states that passed oral-parity legislation , there is no evidence that premiums have risen . Also , in Dr . Dusetzina ’ s study , overall costs ( insurance payments for OAMs plus OOP costs ) did not increase for patients covered under state parity laws .
“ We also didn ’ t observe any huge shift in use of drug , suggesting that there was no pent-up demand that wasn ’ t being met before parity was available ,” said Dr . Dusetzina . “ There might have been a small subset of patients who were able to afford their treatment post-parity , but what other [ studies ] have shown is that people will generally do what they need to do to get access to their cancer therapies .”
For Dr . Rosmarin , all roads lead to the same place : “ We just want to be able to deliver to our patients the care that they ought to be getting , and it breaks your heart to see financial or social barriers that might get in the way of best possible care .”— By Debra L . Beck ●
REFERENCES
1 . Dusetzina SB . Drug pricing trends for orally administered anticancer medications reimbursed by commercial health plans , 2000-2014 . JAMA Oncol . 2016 ; 2:960-1 .
2 . Doshi JA , Li P , Huo H , Pettit AR , Armstrong KA . Association of patient out-of-pocket costs with prescription abandonment and delay in fills of novel oral anticancer agents . J Clin Oncol . 2018 ; 36:476-82 .
3 . Dusetzina SB , Huskamp HA , Winn AN , et al . Out-of-pocket and health care spending changes for patients using orally administered anticancer therapy after adoption of state parity laws . JAMA Oncol . 2017 November 9 . [ Epub ahead of print ]
4 . Congress . gov , “ H . R . 1409 - Cancer Drug Parity Act of 2017 .” Accessed May 2 , 2018 , from https :// www . congress . gov / bill / 115th-congress / house-bill / 1409 .
5 . Anderson GF , Reinhardt UE , Hussey PS , Petrosyan V . It ’ s the prices , stupid : Why the United States is so different from other countries . Health Aff ( Millwood ). 2003 ; 22:89-105 .
6 . Wang B , Joffe S , Kesselheim AS . Chemotherapy parity laws . A remedy for high drug costs ? JAMA Int Med . 2014 ; 174:1721-2 .
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