Patient Cost Burden for Metastatic Breast Cancer Therapy

Steven Peskin, MD, MBA, FACP, provides insight into the patient cost burden and the various medical plans.


Bruce Feinberg, DO: Steve, Joyce brought up the issue of cost and benefit design, which is often a key issue in patient care, particularly noteworthy in oncology where we’re dealing with life-and-death disease. Insurers have to be struggling with this constantly. Do you like having an arbiter, like an ICER [Institute for Clinical and Economic Review], that would have that kind of clarity to provide? You said you get around the off-label and some of the other problems. But in doing so, would a trade-off be that if there was that arbiter that said this is the appropriate therapy in this patient at this time, that would remove those prohibitive costs on the patient? I know you speak for yourself and your 1 plan, but where do you see the industry going?

Steve Peskin, MD, MBA, FACP: It’s a really profound question, Bruce, and patient cost burden and what individuals will bear from an out-of-pocket or patient-cost-burden perspective varies widely. We have some plan sponsors that have very—we’ll call them generous plan designs, where there are limited out-of-pocket costs. There are products that people purchase with eyes wide open—never thinking, perhaps like Kelli, about getting cancer—through the Affordable Care Act, the ACA. There’s a fancy term called actuarial value for bronze, silver, gold, and platinum, Bruce’s so-called metallics. The bronze would be less generous. A person may well find herself or himself with high out-of-pocket costs that she or he potentially could not afford, and then working with Bill or Joyce, looking at what those treatment alternatives might be within the construct of affordability. There are other complexities associated with the site of service. It might be actually less expensive for the person to get an infusion therapy versus an oral because of the way the plan is structured and designed for patient out-of-pocket expense. There is a lot of complexity there.

I wish I had the answers. I guess I might be health czar if I did. There’s a lot to unpack in your question, and I’d say there are no easy answers. Joyce mentioned there are foundations out there that do good work to support people’s patient cost burden. Then there are decisions. You mentioned ICER. There’s the National Institute for Health and Care Excellence in England, which people look to sometimes from across the pond. There’s the ASCO [American Society of Clinical Oncology] Value Framework. NCCN [National Comprehensive Cancer Network] more recently in its guidelines included some economic considerations. Kelli mentioned the notion of natural toxicity as well. There is a lot to unpack there.

Bruce Feinberg, DO: Kelli, I’m curious how far to go. I never know in a situation like this, you know. How have you been able to afford your therapies?

Kelli Davis: I’ve run the gamut between having private insurance—I worked for corporate Walmart for 20 years, and until about 3 years ago, I was still working there. They’ve pretty much covered everything. My insurance was phenomenal. I paid $50 a month for my premium, and it was pretty much seamless. Then I retired and I went on to a COBRA situation, where the premium was much higher, and then had much greater out-of-pocket expense, obviously. Transitioning onto Medicare, where the doughnut hole is quite large, has been a challenge. That is the way I was able to afford medicine—the Ibrance and Faslodex together are around, I guess, $24,000 a month. I have great relationships with pharmaceutical companies, and I was able to get a grant through Pfizer to cover the cost of the medicine. The co-pay is around $2000 a month. I wonder if that is because I had a relationship or because that information is readily available to patients. I worry sometimes that—

Bruce Feinberg, DO: Yeah, well, speaking for 6000 patients didn’t hurt.

Kelli Davis: Yeah, and that’s what I do. I share what I learned with the forums and with people who need to know this. I’m probably responsible for some of the posturing and people who are asking questions: Can I do this, can I do that? I want patients to be informed, and I want them to be able to ask the questions and feel comfortable. It’s an uncomfortable conversation, especially when you have payers and you have oncologists at the table. We have to ask these questions because we have to learn, and we have to be part of this conversation, even if it means being a little bit of a thorn in the side. We have PhDs too. That’s something that most payers or oncologists or researchers don’t understand, because we live with this beast every single day. I was able to get the assistance through Pfizer to cover it. When I transitioned to Medicare, I was no longer eligible for that support, so I had to go find—and continue to have to find—philanthropic support to get that covered. Thank goodness my clinic has a phenomenal social working area that actually helps with this, because every 2 months the fund dries up and we go find something else to cover it. I’m just conditioned to being ready to get that call or that letter saying, “Kelli, the money is out. Let’s go ahead and figure out what else we can do.”

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