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Payer Administrative Barriers Limit Access to Cancer Care

The American Society of Clinical Oncology says clinical pathways will reduce administrative burdens that limit patient access to cancer care.

Utilization management and administrative burdens limit patient access to cancer care.

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Healthcare payers should reform their utilization management strategies and reduce administrative barriers to better facilitate easy access to cancer care, says the American Society of Clinical Oncology (ASCO).

Utilization management strategies include step therapy, prior authorization requirements, restrictive drug formularies, and specialty-specific tiers. Healthcare payers use these requirements to control drug spending for beneficiaries.

Despite the need to control drug costs, ASCO contends that utilization management restricts patient access to effective treatments, especially for cancer patients.

“In many cases, oncology drugs do not have substitutes that are both equally effective and less expensive for a given patient,” the organization said in a public statement. “Consequently, policies that attempt to incentivize, force, or coerce patients to accept anti-cancer therapy alternatives that are not recommended by their oncologist can threaten both the outcomes for patients and the well-being of their families or caretakers.”

Many existing administrative processes specifically target cancer patients. While ASCO did not insinuate that this targeting is malicious, administrative barriers can still be unfair and potentially disastrous to a cancer patient’s health.

Step therapy, for example, can delay a patient’s access to the most effective drug for her treatment regimen. Step therapy requires patients to exhaust a list of preferred treatments – often deemed preferred due to low costs – before graduating to the most effective, and often most expensive, treatment.

The logic behind step therapy states that drugs within a certain treatment category are loosely interchangeable. In oncology, however, this is often not the case.

“Step therapy policies are generally inappropriate in oncology due to the individualized nature of modern cancer treatment and the general lack of interchangeable clinical options,” ASCO explained. “Medically appropriate cancer care demands patient access to the most appropriate drug at the most appropriate time.”

Other utilization management techniques, such as specialty tiers or greater cost-sharing for oral drugs, also hinder patient access to effective cancer treatment by presenting financial barriers.

Specialty tiers can drive the out-of-pocket patient costs for a certain drug, barring many patients from purchasing the treatment.

“A drug placed on a specialty tier can result in patient coinsurance payment as high as 30 to 50 percent of the drug’s costs. Anti-cancer drugs on a specialty tier may provide the best—or only—treatment option for individual patients,” ASCO pointed out.

In cancer care, there is usually no alternative option that is also effective for an individual patient’s cancer. Specialty tier requirements are thus asking patients to make treatment decisions based on their ability to pay for a drug and not on what is clinically effective, ASCO said.

Many payers also often impose higher cost-sharing for oral chemotherapy drugs that are covered under prescription drug benefits than they do for intravenous chemotherapy that is covered under medical benefits.

ASCO argues that this limits cancer patients. Due to the specific nature of the disease, cancer patients cannot simply pick and choose which treatments they receive. Oral chemotherapy may offer the most beneficial treatment for the patient, and patients should not be financially penalized for that, ASCO said.

Although ASCO argued against many utilization management strategies, it did acknowledge the need for health payers to control drug costs.

“ASCO believes that well-designed, high-quality clinical pathways should be the first choice of payers to ensure appropriate utilization of anti-cancer drugs and the delivery of high-value care,” ASCO offered.

Clinical pathways, when designed correctly, use evidence to determine treatment steps for specific care needs. Using streamlined treatment techniques, clinicians and payers can create a treatment protocol that is both financially sound and effective.

“A well-designed clinical pathway matches specific clinical diagnoses with evidence-based treatment protocols, allowing patients to access high-cost drugs when medically appropriate,” ASCO explained. “Well-designed clinical pathways also have flexibility to allow providers to treat patients ‘off-pathway’ when warranted clinical circumstances for variation exist.”

ASCO called for health payers to change traditional utilization management strategies for clinical pathways. Additionally, the organization called for legislation to block certain utilization management practices, such as specialty tiers or higher cost-sharing for oral chemotherapy.

These actions will ideally improve access to effective treatments for cancer patients.

"Utilization management strategies, when implemented without appropriate patient safeguards, can impede patient access to high-value, clinically appropriate care," said ASCO President Daniel F. Hayes, MD, FASCO, FACP. "Payer policies must reflect the current requirements of contemporary cancer care and be evidence-based on what constitutes high-quality care."