Ripple Effect: Medicare and Hospice

MARCH 01, 2005

Cost can be a hurdle for cancer patients when oral treatment is necessary. Patients who are employed or otherwise covered by insurance that includes a prescription drug benefit may not find cost a barrier (unless they exceed their reimbursement cap, the agent is nonformulary, or they cannot afford the copayment). Medicare does not routinely reimburse for medications dispensed through a pharmacy for outpatient use. Medicare patients may have difficulty paying for the drug. Because more than 50% of all new cases of cancer occur in patients who are older than age 65, this issue is of considerable concern. As this article was written, 30 tablets of gefitinib 250 mg cost $1805.91; 30 tablets of imatinib 400 mg cost $2299.00; 5 capsules of temozolomide 100 mg cost $743.98; and 30 tablets of bicalutamide 50 mg cost $382.94, as reported by Clearly, elderly patients on limited incomes could have difficulty paying for these drugs in the short or long term. Medicare launched a pilot program in September 2004 to try to help seniors who were on high-cost drugs, and antineoplastic chemotherapy was a priority for them. As the Medicare drug benefit becomes a reality, it is hoped that seniors will receive these drugs with only a copayment, especially since employing oral agents represents a cost savings to the Medicare program over intravenous drugs in many cases.

Hospice providers also report some backlash from greater availability of oral chemotherapy. They indicate that fewer side effects and the ability to take medications at home may reinforce a long-standing reluctance to accept that death is approaching. Patients, ever hopeful, may have a false optimism or unrealistic expectations concerning the new orals. Patients may defer enrolling in hospice (which allows only palliative treatment), or clinicians may wait to refer patients while they try a newer oral medication at the patient's request. The impact of this delay is that patients do not derive the full benefit of hospice care and may suffer needlessly.

Sources: O'Neill VJ, Twelves CJ. Oral cancer treatment: developments in chemotherapy and beyond. Br J Cancer. 2002; 87:933-937; McCullough. More anti-cancer drugs are coming out as pills. Knight Ridder/Tribune. August 4, 2002:K1271; DeMario MD, Ratain MJ. Oral chemotherapy: rationale and future directions. J Clin Oncol. 1998;16:2557-2567.