Editor’s Desk

Patient assistance programs are a ‘double-edged sword’

Peter Wehrwein

Regardless of what you might think about the ACA, there's no question that it has changed the terms of the never-ending debate about the inadequacy of American health care. Cost, not coverage, is dominating the discussion.

No, the exchanges are not out of the woods. But the combination of Medicaid expansion and the ACA exchanges meant that number of American adults without health insurance dropped pretty dramatically from 16.3% in 2014 to 12.8% in 2015, according to the federal government's National Health Interview Survey.

In a piece for the Wall Street Journal last week, Drew Altman, president and chief executive officer of the Kaiser Family Foundation, noted high deductibles are now the top health-cost issue for consumers. As Altman pointed out, high deductibles are having a profound effect on how Americans view and experience health care. They are seeing dollar signs everywhere, electing to forgo certain treatments (you might call this self-rationing), and accepting of cheaper forms of delivery, like telemedicine.

Medications are a double whammy in this era of expanded coverage but with higher out-of-pocket costs. For many conditions, treatment drugs have become fantastically expensive while plan design shifts costs to the patient through dark-art combinations of the deductible, coinsurance, and the like.

The growing number and size of patient assistance programs has been one response to these developments.

But Robert W. Carlson, M.D., the CEO of the National Comprehensive Cancer Network (NCCN) and a medical oncologist at Fox Chase Cancer Center in Philadelphia, called the programs a "double-edged" sword last week during an Association of Health Care Journalists webinar on the "financial toxicity" of cancer treatments. Joseph Burns, the association's topic leader on insurance issues and a contributing editor to Managed Care, moderated the session.

Carlson said to the journalists watching online that cancer treatment is now the leading cause of personal bankruptcy, noting that the new wave of treatments sweeping through oncology are priced, on average, at $10,000 a month. NCCN has added "affordability" as category to its "evidence blocks" for evaluating a treatment, he explained, along with efficacy, safety, the quality and quantity of evidence for a treatment, and the consistency of the evidence.

Patient assistance programs are, in fact, effective in shielding individuals from the crushing costs of new medications. Carlson told the story of a patient of his with metastatic, hormone receptor–positive breast cancer. Pfizer's new drug, palbociclib (Ibrance) was a treatment option but at roughly $10,000 a month, "affordability was an issue." The patient's insurance company told the patient that her cost would be $500 a month, but that was still too large of an expense. Ultimately, a patient assistance program got the patient's expense down to $10 a month. Carlson noted, though that the expense doesn't go away but is shifted and the drug company "still comes out ahead of the game."

Patient assistance programs are "good for the individual patient but perhaps not so good on a societal basis," he said.