Ripple Effect: Medicare and Hospice

Cost can be a hurdle for cancerpatients when oral treatment is necessary.Patients who are employed orotherwise covered by insurance thatincludes a prescription drug benefitmay not find cost a barrier (unlessthey exceed their reimbursementcap, the agent is nonformulary, orthey cannot afford the copayment).Medicare does not routinely reimbursefor medications dispensedthrough a pharmacy for outpatientuse. Medicare patients may have difficultypaying for the drug. Becausemore than 50% of all new cases ofcancer occur in patients who areolder than age 65, this issue is ofconsiderable concern. As this articlewas written, 30 tablets of gefitinib250 mg cost $1805.91; 30 tablets ofimatinib 400 mg cost $2299.00; 5capsules of temozolomide 100 mgcost $743.98; and 30 tablets of bicalutamide50 mg cost $382.94, asreported by drugstore.com. Clearly,elderly patients on limited incomescould have difficulty paying forthese drugs in the short or long term.Medicare launched a pilot programin September 2004 to try to help seniorswho were on high-cost drugs,and antineoplastic chemotherapywas a priority for them. As theMedicare drug benefit becomes areality, it is hoped that seniors willreceive these drugs with only acopayment, especially since employingoral agents represents a cost savingsto the Medicare program overintravenous drugs in many cases.

Hospice providers also report somebacklash from greater availability oforal chemotherapy. They indicatethat fewer side effects and the abilityto take medications at home mayreinforce a long-standing reluctanceto accept that death is approaching.Patients, ever hopeful, may have afalse optimism or unrealistic expectationsconcerning the new orals.Patients may defer enrolling in hospice(which allows only palliativetreatment), or clinicians may wait torefer patients while they try a neweroral medication at the patient'srequest. The impact of this delay isthat patients do not derive the fullbenefit of hospice care and may sufferneedlessly.

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