The use of specialty pharmaceuticals to treat patients with cancer is rapidly increasing as oncology continues to shift toward targeted, personalized therapies. However, with an average annual cost of more than $78,000 for a single specialty drug,1 these treatments can present significant affordability issues for patients. Results from several studies show the staggering effects of high health care costs on patients with cancer:
  • More than 29% of patients in the United States have not filled a prescription or have reduced their prescribed dose because of high costs.2
  • More than 1/3 of patients with cancer had out-of-pocket (OOP) costs that were higher than they expected, with 16% reporting great or overwhelming financial distress, and health care costs that were consuming nearly 1/3 of their income.3
  • A study presented at the 2014 Palliative Care in Oncology Symposium found 27% of cancer survivors reported suffering a financial problem, such as bankruptcy, and another 37% reported modifying work plans or delaying retirement.
  • In a study of 9.5 million cancer survivors aged 50 years or older, more than 40% had exhausted their life savings and all other assets 2 years after diagnosis.4
Nearly 28.5 million Americans are uninsured or underinsured,5 leaving them at risk for medical and pharmaceutical costs they may not be able to afford. As OOP costs increase, patients are more likely to delay or discontinue treatment, despite that their overall health may be dependent on being adherent.

Oncologists have grown increasingly concerned that high costs create ‘financial toxicity’6 and may keep patients from getting needed treatments. The American Society of Clinical Oncology considers discussing costs with patients crucial to providing quality care. By offering financial counseling and assistance, hospitals and health centers can help patients access the care they need.

Effective Hospital Pharmacies Support the Patient
Patient assistance programs (PAPs) operated by pharmaceutical manufacturers, nonprofit organizations, and government entities are designed to relieve financial pressures by helping those in need obtain their medications. Currently, there are 372 programs and companies covering more than 4100 drugs.7 Assistance generally comes in 2 forms:
  • Copayment assistance: These programs help reduce the patient’s OOP responsibility, including coinsurance and deductible support, depending on treatment setting.
  • Replacement drugs: The hospital pharmacy provides the prescription medication to the patient for free, and the drug manufacturer replaces the product back to the provider at no cost.

One of the challenges in securing PAP aid is proactively monitoring changes in patient eligibility and documentation requirements. Most PAPs require an application, yet no 2 programs are the same, and the amount of information required varies. Some programs require detailed medical and financial information, and others ask for very little. In addition, although all require a physician’s signature, some programs require the doctor to complete a portion of the form, and others only need a signed prescription.

However, many hospital and health-system pharmacies lack the infrastructure and staff resources to constantly monitor hundreds of assistance programs and gather patient data to manage the PAP process effectively. Having a dedicated in-house manager, and outsourcing program administration to a third party with clinical and financial expertise can maximize the pharmacy’s drug recovery savings, and increase overall patient satisfaction.

For example, McKesson’s PAP Recovery team helps hospitals successfully manage evolving PAP complexities by providing recovery services, which include identifying eligible patients, completing and verifying enrollment, and facilitating product recovery.

Technology designed to store patient data, auto-populate required forms, and streamline and track the status of PAP applications can alleviate many challenges, and save pharmacy staff valuable time. This results in increased patient enrollment and drug replacements for health-system pharmacies, reduced strain on hospital staff resources, and improved regulatory compliance.

Although specialty drugs do not require different enrollment procedures, they can present additional complexity, as some treatments are covered under medical benefits rather than pharmacy benefits. For example, infused and in-office–administered treatments often require medical benefit copay programs. Depending on a patient’s treatment regimen and provider coverage, brands may offer medical and/or pharmacy benefit support.

This complexity does not affect the patient, because their need for access does not change. However, it does require that hospitals proactively manage their PAPs across several hospital or health-system departments.

To best manage PAP eligibility at patient intake, communication needs to be clear and frequent between the PAP team and the team that conducts benefits investigations to most efficiently identify the therapies needed to treat eligible patients, and PAPs that are available to aid in the patient’s care.

Additionally, if included with the PAP application, the data collected during the benefits investigation and prior authorization process may speed enrollment and approval while reducing treatment delays.

The Savings for Hospitals and Patients
Over the past year, the McKesson team has worked with 350 hospitals and health systems to support more than 13,000 patients; coordinate more than 21,400 free drug shipments; and save patients more than $160 million.8 Whether this covers $500,000 for a newly approved immunotherapy or $1200 every 3 weeks for chemotherapy, PAPs represent a lifeline for patients who, without assistance, could not otherwise afford their medications.

For example, an elderly couple was referred to our team because they could not afford to complete the wife’s chemotherapy treatments. The couple had decided that if no assistance was available, she would discontinue treatment. According to the wife, “I cannot leave my husband here on Earth knowing he has no income or way to survive, and I refuse to break us because all the medicine is doing is giving me a little more time with him.”

The PAP team submitted an application and worked exhaustively on 4 appeals over 2 months, calling the manufacturer regularly until finally receiving approval for free medication. The couple was overjoyed, and they can be seen each week walking into the cancer center for her treatments holding hands.

PAP Programs Driving Cancer Patient Access
As health care costs continue to increase, caring for disadvantaged patients will have a significant financial impact on hospitals and health systems. When 1 in 6 emergency department visits results in a surprise bill,9 we encourage health systems to review their pharmacy operations for the opportunity to implement a PAP. With the help of PAPs, your organization can ensure that patients receive cost-effective medications they need while helping you recover considerable savings.
 
O`Mally Monahan is a senior director with McKesson RxO, McKesson’s pharmacy consulting and technology team specializing in value-add services for health system customers. She has more than 15 years of health care experience including patient assistance program implementation, operations, customer engagements and using agile development to design and enhance software.


REFERENCES
  1. Purvis, Leigh, and Stephen W. Schondelmeyer. Rx PriceWatch Reports. Washington, DC: AARP Public Policy Institute, June 2019. https://doi.org/10.26419/ppi.00073.000. Accessed October 10, 2019.
  2. Bi-Partisan Majorities Support Range of Policy Changes Aimed at Lowering Drug Costs. Nearly 1 in 4 Americans Taking Prescription Drugs Say It’s Difficult to Afford Their Medicines, including Larger Shares Among Those with Health Issues, with Low Incomes and Nearing Medicare Age. Kaiser Family Foundation website. https://www.kff.org/health-costs/press-release/poll-nearly-1-in-4-americans-taking-prescription-drugs-say-its-difficult-to-afford-medicines-including-larger-shares-with-low-incomes/. Published March 21, 2019. Accessed October 10, 2019.
  3. Chino F,  Peppercorn J, Rushing C, et al. Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care, JAMA Oncol. 2017;3(11):1582-1584. doi:10.1001/jamaoncol.2017.2148. Accessed October 10, 2019. 
  4. Gilligan, A. M., Alberts, D. S., Roe, D., & Skrepnek, G. H. (Accepted/In press). Death or Debt? National Estimates of Financial Toxicity in Persons with Newly-Diagnosed Cancer. American Journal of Medicinehttps://doi.org/10.1016/j.amjmed.2018.05.020. Accessed October 10, 2019.
  5. United States Census Bureau. Health Insurance Coverage in the United States: 2017. https://www.census.gov/content/dam/Census/library/publications/2018/demo/p60-264.pdf. Published September 2018. Accessed October 10, 2019.
  6. S. Yousuf Zafar, Amy P. Abernethy, Financial Toxicity, Part I: A New Name for a Growing Problem. Oncology (Williston Park). 2013 Feb; 27(2): 80–149. Accessed October 10, 2019.
  7. Need My Meds. https://www.needymeds.org/. Accessed October 10, 2019.
  8. McKesson data on file.
  9. Pollitz K, Rae M, Claxton G, et al. An Examination of Surprise Medical Bills and Proposals to Protect Consumers from Them. Peterson-Kaiser Health System Tracker. https://www.kff.org/health-costs/issue-brief/an-examination-of-surprise-medical-bills-and-proposals-to-protect-consumers-from-them/. Accessed October 10, 2019.