A new drug that cures, or at least delays, a deadly disease like cancer represents a huge advance — unless no one can afford it. Innovation without access is meaningless.
In the past five years, we have witnessed the emergence of revolutionary scientific innovations for treating cancer such as immunotherapies, targeted oral cancer medicines, gene therapies, and more. These new approaches are turning many daunting cancers into manageable conditions.
These new advances won’t realize their full potential, however, unless patients have access to them. As long as patients struggle to pay out-of-pocket costs or are unable to access medicines that may save their lives, the promise of these new therapies goes unfulfilled. This is particularly true for older Americans, who are more likely to develop cancer than younger individuals and who may be living on fixed incomes.
Since its inception in 2006, Medicare Part D has filled a longstanding gap for this population, serving as an effective market-based solution that provides seniors with affordable access to the vast majority of the medicines they need to stay healthy.
Part D has remained relatively unchanged over the last 13 years while revolutionary advances have occurred in the development of complex cancer therapies. As a result, there are now legitimate concerns that Part D, while still an invaluable asset for most health conditions, is falling short in providing protection for seniors who rely on specialty treatments to battle cancer and other deadly diseases.
Current Part D benefit designs result in high out-of-pocket costs for many seniors. Over 40% of cancer treatments covered by Part D require more than $250 in out-of-pocket payments for each prescription. That’s a problem because high cost sharing has been linked to reduced adherence to medicines, risking the health of this vulnerable population. In addition, Part D is front loaded, forcing seniors to bear most of the costs at the beginning of the “donut hole,” which seniors must get through before catastrophic coverage kicks in.
When it comes to affordability, all stakeholders have roles to play. Biopharmaceutical companies like the one I lead must work creatively and collaboratively with insurers, pharmacy benefit managers, federal and state governments, and others to provide access to prescribed therapies. We also have a responsibility to ensure that our medicines are priced fairly in a way that reflects the innovation and value they deliver to patients, health care systems, and society.
I see four ways to help Medicare Part D evolve with the rapid pace of medical innovation so the focus remains on access. These practical approaches, which directly address benefit design, can be implemented without fundamentally changing the program’s successful competitive structure.
First, when drug companies negotiate discounts and rebates with insurers and pharmacy benefit managers, those savings should be passed directly to Part D beneficiaries. It’s the right thing to do, and will only serve to benefit patients. The Department of Health and Human Services recently proposed a rule in this vein that would be a step in the right direction. This alone, however, will not bring enough relief to seniors.
Second, patients should be given the option of spacing their out-of-pocket costs for specialty medicines over time, instead of burdening them with unreasonably high payments upfront. This would allow seniors to better plan for the cost of their treatments. If utility companies can do this with heating and air conditioning bills, Medicare can do it for medications.
Third, if a physician deems that a particular therapy is most effective for treating an individual’s illness, she or he should be able to request lower cost sharing for the drug even if it isn’t on the insurance plan’s preferred “tier.” Insurers should acknowledge that patients do not respond identically to specific medicines, and long-term savings can be achieved by getting the treatment right the first time.
Fourth, just as Medicare Advantage caps annual out-of-pocket spending for hospital care, laboratory tests, and other services, Part D should do the same thing for spending on medications. It is unjust to saddle seniors with unlimited, uncapped spending merely because they are able to manage their medical condition at home with prescription therapies, rather than through costly medical procedures and hospital care.
An estimated 1.7 million Americans, many of them over age 65, will be diagnosed with cancer this year. Medicare Part D has been an unequivocal success for millions of aging Americans, but it is now falling short in protecting those facing some of the most deadly cancers. As new discoveries are made that can extend the lives of people with cancer, modernizing Medicare Part D isn’t just a matter of public policy. It’s a pathway to hope and the prospect of living life to the fullest.