Out-of-Pocket Costs for Oral Oncolytic Agents

As a payer, Brian B. Kiss, MD, vice president, healthcare transformation, Blue Cross Blue Shield of Florida, acknowledges that benefit design is complex and the benefit structure for end-of-life care can be funded differently. “We’re working on the system to make these decisions,” he says. Plan designs are shifting toward out-of-pocket maximums; a patient receiving chemotherapy treatment will almost certainly reach that maximum cost-sharing limit, and possibly after only 1 month of therapy.

“The benefit design is a nightmare,” states Bruce A. Feinberg, DO, vice president and chief medical officer of Cardinal Health Specialty Solutions. Frequently, benefit design does not take the personalized aspect of medicine into account, which is so important in palliative care. It is important that benefit design alleviates the problem, he adds.

Dr Kiss believes that we need benefit designs that will not hinder patients from taking oral oncolytics or filling a prescription. It is important to have a value-based benefit design that motivates patients to do the right thing for themselves, notes Dr Kiss, and this is even more critical in palliative care. There should be as little obstruction as possible for patients to fill that prescription or take that full prescribed dose.

As payers we need to address some of those structural issues and that may mean “looking at changing and moving to value-based benefit design,” says Dr Kiss.