Financial realities of fighting cancer: A close look at patient responsibility with part D coverage.

12 Background: Medicare Part D, a prescription drug plan offered by government-contracted private payers, provides coverage for prescription drugs. The plan design encompasses the deductible, initial coverage (IC), coverage gap (CG), and catastrophic coverage (CC) phases. In the earlier phases, patients bear a significant financial burden for drug costs (100% of the deductible, 25% of drug costs during IC and CG) until they reach the out-of-pocket threshold (OOPT) and transition to the CC phase, where the responsibility decreases to 5% of the drug cost with no upper limit. Additionally, Medicare subsidizes or assumes full responsibility for low-income patients through the Low-Income Cost Subsidy (LICS) benefit. We analyzed the patient responsibility (PR) for cancer patients under Medicare Part D and the impact of Part D Anti-Neoplastics (PDAN). Methods: Using Medicare Part D prescription data for 15 practices in The US Oncology Network, we obtained and evaluated the gross drug costs below (GDCB) and above (GDCA) the OOPT, LICS and estimated PR for prescriptions over a 6-year period (July 2016 – June 2022). Results: The analysis of 5.12 million prescriptions for 99,623 cancer patients reveals that 1 in every 5 patients surpassed the OOPT and transitioned to the CC phase. Among the patients receiving PDAN drugs, 3 in every 4 crossed the OOPT. Table 1 provides the percentage of patients entering the CC phase and the estimated per patient, per year PR amounts. Within the PDAN drug recipient group, 85% of patients who reached the OOPT did so within the first 3 months of initiating therapy, often after just 2 prescription dispenses, resulting in a significant portion of the PR being incurred upfront. Approximately 45% of the PR was accumulated prior to crossing the OOPT. Interestingly, only 1 in every 5 patients receiving generic PDAN drugs surpassed the OOPT, in contrast to every patient receiving a branded PDAN. Additionally, patients receiving generic PDAN incurred lower PR costs. About 1 in every 6 patients benefited from the LICS, with 60% of the LICS amounts being paid within the first 3 months of starting therapy, aligning with the timing of patients entering the CC phase. Conclusions: Cancer patients, particularly those taking PDAN drugs, face significant PR costs. The proposed changes to the Part D plan design outlined in the Inflation Reduction Act (IRA) aim to alleviate this burden by reducing PR. These changes include reducing PR in the CC phase to 0%, capping PR in the earlier phases at $2000 and changing cost-sharing between plans, manufacturers, and Medicare. However, the potential effects of these adjustments on Part D plan premiums remain uncertain and require further examination. Without PDAN Drugs With PDAN Drugs Total % of patients Not crossing OOPT 94% 22% 80% Crossing OOPT 6% 78% 20% Patient Responsibility for Patients Not crossing OOPT $292 $1,787 $373 Crossing OOPT $2,448 $6,525 $5,555 Total $422 $5,489 $1,424