ASCO 2016: Patients With Cancer With ACA Policies Swiftly Reach Out-of-Pocket Caps

Key Points

  • Researchers found that their hypothetical CML patient, paying only for drugs and not counting premiums and deductibles, reached that out-of-pocket maximum in 1 month with 70% of bronze-level plans and half of the silver plans.
  • In 3 months, he would reach his annual out-of-pocket maximum with 79% of bronze plans and 91% of silver plans.
  • As expected, at 100% of the poverty level, silver plans provided better protection than bronze plans from out-of-pocket costs. At 200% of the poverty level, however, median annual out-of-pocket costs were much more variable for both silver and bronze plans. At 300% of the poverty level, a bronze plan was more beneficial than a silver plan. The patient at this income level would pay $1,470 less in annual out-of-pocket expenses on average than the same patient with income at 100% of the poverty level. 

Duke Cancer Institute researchers have found that a hypothetical leukemia patient buying the life-extending drug therapy for his condition would reach his annual out-of-pocket maximum in a month on most of the bronze policies and half of the silver policies offered through the Affordable Care Act marketplace.   

The findings, reported by Gable et al at the 2016 ASCO Annual Meeting (Abstract 6504), revealed that cancer patients buying health insurance coverage through the Affordable Care Act marketplace should take into account annual premiums, out-of-pocket maximums, and potential treatment costs—not just one or another of those factors. Even then, the coverage level did not necessarily predict the amount of expected out-of-pocket costs.

“When when using all those criteria, the least expensive choice for patients was often the lower tier policies—typically sold as the ‘bronze’ option—but not always,” said senior author Yousuf Zafar, MD, Associate Professor in the School of Medicine and the Sanford School of Public Policy at Duke University. “Patients might assume that the bronze policy would be the least expensive compared to silver or gold levels, but it’s important to shop carefully, particularly when considering out-of-pocket expenses.”

Study Details

Dr. Zafar and colleagues gathered data using the HealthCare.gov insurance exchange in North Carolina and searching as a “secret shopper” for a hypothetical 55-year-old male patient with chronic myelogenous leukemia (CML). 

CML was selected because it is a chronic disease requiring years of expensive but potentially life-extending treatment. The primary treatment for CML, imatinib, is an oral anticancer therapy and is the 24th highest selling drug in the United States. High monthly co-payments can reduce adherence to the drug.

The hypothetical patient was also assigned varying incomes, from 100% to 300% of the poverty rate. Using those criteria, the hypothetical patient was eligible for 141 bronze and 210 silver plans across six counties.

Excluding premiums, the maximum amount all insurance exchange policyholders must pay out-of-pocket is $6,850—an amount that represents approximately 10% of median household income in the United States.

Study Findings

The Duke researchers found that their hypothetical CML patient, paying only for drugs and not counting premiums and deductibles, reached that out-of-pocket maximum in 1 month with 70% of bronze-level plans and half of the silver plans. In 3 months, he would reach his annual out-of-pocket maximum with 79% of bronze plans and 91% of silver plans.

As expected, at 100% of the poverty level, silver plans provided better protection than bronze plans from out-of-pocket costs. At 200% of the poverty level, however, median annual out-of-pocket costs were much more variable for both silver and bronze plans. At this income level, the hypothetical patient would see little difference in average costs between silver and bronze plans, but would face more choices within silver plans.

Contrary to conventional wisdom, the researchers found that their hypothetical patient with income at 300% of the poverty level was more likely to benefit from a bronze plan than a silver plan. The patient at this income level would pay $1,470 less in annual out-of-pocket expenses on average than the same patient with income at 100% of the poverty level. 

“The Affordable Care Act has improved access to health care for millions of Americans who would have otherwise done without,” Dr. Zafar said. “But what remains unclear is whether health care for patients—particularly those who face chronic illness—will be affordable enough.”

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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