How have high cancer drug costs affected your patients?

Dr. Strup“In Kentucky, we have a unique blend of patients. We have very high-end, influential patients who will seek every available therapy and have the means to pay. If the insurance pays, fine. If not, they just write the check.

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Then there’s the ‘average Joe’; we have a ton of those. Financial issues do come up there. Most of them have enough reasonable insurance that works as long as you’re following a pathway. But if you start deviating from the pathway, for whatever reason, you meet resistance. When you start to use drugs in not well-described, not well-documented pathways, you don’t have much flexibility. That’s when patients in the middle ground run into trouble.

Then there are Medicaid and all the supported plans. They are very restrictive. They’ll say, ‘You’ve got to use interferon first’. Well, interferon hasn’t been used in 20 years! Why would we want to do that?

You end up in an argument with their industry-supported physician, trying to get them to spend money. We get it; these drugs are incredibly expensive, especially in renal cell. They’re maintenance drugs. You don’t take them for a week and stop. It’s a huge expense.

Those are the three tiers I see. The lower you go, the more restrictive plans become. I would say we win the battle about 80% of the time, as long as we’re on an appropriate care pathway.

It comes down to co-pays, but usually companies try to come up with plans to cover co-pays.

If you’ve tried the standard drug and it doesn’t work, you’re really fighting a battle. I’ve had one patient say, ‘It’s not worth it.’ He made the conscious decision that his survival chances are very slim. Even if he gets reasonable co-pays, he would deplete his family’s resources just to drag the disease process out in another 3 months. That was a hard conversation and a tough decision.

With renal cancer, there’s a whole slew of new medications and questions about which are the most efficacious. There’s no one to actually say what the standard of care is. Things move fast. That makes getting coverage harder.

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In the university setting, some risk is removed because we have university pharmacies that can maintain the expense, and we can balance it out by finding patients who are eligible for protocols. In most cases, those drugs are taken care of.”

Stephen Strup, MD

Lexington, KY

Next: Difficutly with deductibles 

Dr. Takesita“I have run into a few patients who have had difficulties with their deductibles and co-pays for those drugs. In the Inland Empire in Southern California, we have a large middle- to lower-income population of Medi-Cal and Medicaid patients, so the co-pay issues are a huge problem for drugs in general, and in a small number of people I prescribed cancer drugs to, it is a problem.

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Fortunately, most of the companies will have programs patients can apply for where they can get drugs cheaper or for free. I don’t have enough experience yet to know how those work out. I can think of at least one patient who literally stopped taking the drug, couldn’t pay for it, and we tried and couldn’t get the drug approved. That patient just couldn’t get the drug. In another case, a patient did get assistance and got the drug to where he could afford it; that was through the actual pharmaceutical company.

We had some samples we gave the patient who couldn’t afford the drugs, but those only last a short time. I haven’t seen him for a while, so I don’t know how he’s doing. But his PSA was rising quickly with nothing to stop it.

For a lot of these drugs, there is the only one out there in a particular class. It’s not like you can just use a generic or find an alternative-it’s a real problem.

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I have to say on their behalf, the pharmaceutical companies do seem to put a lot of effort into financial assistance. Almost every company will tell you, if you have patients call the 800 number, they certainly try to help. And they’re pretty good, but it doesn’t work all the time, and so far there are no other options out there.”

Ken Takesita, MD

Corona, CA

Dr. Delisio“Patients are definitely running into problems affording these medications. It does affect the way we treat them as we usually have to sit down and talk extensively. A lot of these patients have high-deductible plans, and the idea of factoring in the cost of medications is becoming more of an issue. They have to discuss with their carrier what is covered, what their responsibility will be, and then, in addition, we set up people in our office now to be liaisons with the drug companies to work out either payment plans or discounts for patients so they can receive the medications.

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It probably takes our practitioners about 10 minutes per visit for them to explain, but it takes a lot of time for our staff, in addition to their other job of getting pre-approval from insurance companies, etc. There are a lot more hurdles to jump through.

So far, the high costs haven’t actually impacted the treatment patients receive because we’ve found ways to get them the drugs, but it takes time. There is one insurance carrier that has been requesting we use a different medication for metastatic prostate cancer as first-line therapy, but most times if you write a letter or make a phone call and say, ‘No, I want to give this drug,’ they’ll kind of back down. But they’ve been pushing one versus the other. I don’t know why.

I haven’t had anyone stop treatment because they couldn’t afford the medication.”

John Delisio, MD

Richmond, VA

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