Medicare drug plans that cover seniors like Moore are allowed to
charge steep copayments for the latest cancer medications, whose
cost can run to tens of thousands of dollars a year. About 1 in 6
beneficiaries aren't filling their prescriptions, according to
recent research that has put numbers on a worrisome trend.
Officials at Medicare say they're not sure what happens to those
patients - whether they get less expensive older drugs that
sometimes work as well, or they just give up. Traditionally,
chemotherapy has been administered intravenously at a clinic or
doctor's office. Pills, a relatively new option, are thought to
represent the future of cancer care.
Moore, 65, was operated on in February for an advanced form of
kidney cancer. She said both her cancer and kidney specialists
agreed that a drug called Sutent probably offered the only chance to
keep the disease in check. It's a capsule taken at home.
But she was unprepared for what happened when she went to fill her
prescription.
"I cried," said Moore, who lives in a small town in central
California. "What can you do when the only thing out there that can
maybe give you some quality of life is unaffordable? I was
devastated. I didn't know what to do."
Private insurance companies that deliver the Medicare prescription
benefit say the problem is that drug makers charge too much for the
medications, some of which were developed from taxpayer-funded
research. The pharmaceutical industry faults insurers, saying
copayments on drugs are higher than cost-sharing for other medical
services, such as hospital care.
Others blame the design of the Medicare prescription benefit itself,
because it allows insurers to put expensive drugs on a so-called
"specialty tier" with copayments equivalent to 25 percent or more of
the cost of the medication.
Drugs for multiple sclerosis, rheumatoid arthritis and hepatitis C
also wind up on specialty tiers, along with the new anti-cancer
pills. Medicare supplemental insurance - Medigap - doesn't cover
those copayments.
"This is a benefit design issue," said Dan Mendelson, president of
Avalere Health, a research firm that collaborated in a recent
medical journal study on the consequences of high copayments for the
new cancer drugs.
Cost-sharing should only be used to deter wasteful treatment, he
explained. "It is hard to make the argument that someone who has
been prescribed an oral cancer medication doesn't need the drug,"
added Mendelson.
The study last month in the Journal of Oncology Practice found that
nearly 16 percent of Medicare beneficiaries did not fill an initial
prescription for pills to treat cancer, a significantly higher
proportion than the 9 percent of people with private insurance who
did not follow through.
Forty-six percent of Medicare beneficiaries faced copayments of more
than $500, as compared to only 11 percent of patients with private
insurance. Among people of all ages, 1 in 4 who faced a copayment
over $500 did not fill their prescriptions. Cancer is more prevalent
among older people.
"Obviously, we're leaving a lot of folks off the bus, standing at
the curb, if they can't afford the medications," said Dr. Lowell
Schnipper, who chairs the American Society of Clinical Oncology's
task force on the cost of cancer care. It advises doctors to discuss
costs with patients up front, to avoid surprises.
Medicare officials say there are currently no plans to rework the
design of the prescription benefit.
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But "nobody is more concerned about access than we are," said Dr.
Jeff Kelman, Medicare's chief medical officer.
For many seniors, Kelman suggested, the situation is not as bleak as
what Moore encountered. For example, the prescription plan is
designed so beneficiaries who are poor or near poverty face only
token copays. For the rest, President Barack Obama's health care law
gradually closes the coverage gap known as the "doughnut hole." This
year, the new law provides a 50 percent discount on brand name drugs
for those in the gap.
The gap starts after Medicare recipients and their insurance plan
have spent $2,840 on medications. After that, seniors are
responsible for roughly the next $3,600. Once total spending reaches
about $6,440, Medicare's catastrophic coverage kicks in and
beneficiaries pay only a small amount.
Yet the health care law
could be struck down by the courts or repealed if Republicans win
the White House and Congress next year. Even if the law stands,
assistance after seniors end up in the gap doesn't take away the
initial shock at the pharmacy counter.
"The underlying problem is with the basic structure," said Joe
Baker, president of the Medicare Rights Center, a New-York based
advocacy group. "Even before you get to the doughnut hole, you've
got a problem."
One solution would involve requiring drug plans to lower copayments
for cancer pills. But the trade-off is likely to be an increase in
premiums for all beneficiaries.
Rita Moore had to try to find her own way out of the dilemma. She
lives in Corcoran, Calif., and still works as resident manager of an
apartment building for seniors.
Moore decided to apply to Pfizer's prescription assistance program
for patients who can't afford Sutent and other drugs the company
makes. Pfizer approved a year's worth of free medication, but it
took about two months to collect and review all the medical and
financial paperwork.
"They were very helpful, but it wasn't a fast process," said Moore.
In the meantime, she wasn't being treated. The cancer spread and is
now close to her spine and her body's main artery.
"This is kind of strange," Moore said. "After you've worked all your
life, you get something catastrophic and you run into news like your
drugs are going to cost $2,400."
[Associated Press
RICARDO ALONSO-ZALDIVAR]Copyright 2011 The Associated Press. All rights reserved. This
material may not be published, broadcast, rewritten or
redistributed.
Associated Press Medical Writer Lauran Neergaard contributed to
this report.
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