Impact of Subsidies on Use of Oral Immunomodulatory Drugs in Medicare Beneficiaries With Myeloma


Key Points

  • Median costs for the first year of therapy with oral immunomodulatory drugs for myeloma were more than $5,000 higher in those without a low-income subsidy than in those with a low-income subsidy.
  • Subsidy recipients were less likely to have delays between refills.

According to a study by Olszewski and colleagues in the Journal of Clinical Oncology, Medicare Part D beneficiaries without a low-income subsidy may face daunting barriers in affording oral immunomodulatory drugs for myeloma. The low-income subsidy markedly reduces out-of-pocket costs for qualifying Medicare Part D beneficiaries receiving oral chemotherapy.

Study Details

In the study, Surveillance, Epidemiology, and End Results–Medicare data were used to identify Part D beneficiaries diagnosed with myeloma between 2007 and 2011. The association of low-income subsidy with the use of the immunomodulatory drugs lenalidomide (Revlimid) and thalidomide (Thalomid), delays in immunomodulatory drugs refills, and select health outcomes during the first year of therapy were assessed.

Immunomodulatory Drug Use and Cost

Among 3,038 beneficiaries, 41% received first-line immunomodulatory drugs (42% with low-income subsidy and 41% without low-income subsidy). Patients received an average of 6 immunomodulatory drug prescriptions during the first year of therapy, with a median gross annual drug cost of $39,250. Median duration of first-line immunomodulatory drug therapy was 7.6 months, with 38% of patients continuing therapy for > 12 months.

Median out-of-pocket cost for the first immunomodulatory drug prescription was $3,178 for those without low-income subsidy and $3 for low-income subsidy recipients, and median costs for the first year of therapy were $5,623 and $6. Overall, the catastrophic phase of coverage was reached by 3.9% of all patients just prior to chemotherapy, 65.3% with the first immunomodulatory drug prescription, and 79.4% with the second immunomodulatory drug prescription.

Low-Income Subsidy and Non–Low-Income Subsidy Groups

Receipt of the subsidy was associated with a 32% higher probability of receiving immunomodulatory drugs among patients aged 75 to 84 years and a lower risk of delay between refills across all age groups (adjusted relative risk = 0.54, 95% confidence interval [CI] = 0.32–0.92). Median duration of immunomodulatory drug therapy was 7.6 months in both the low-income subsidy and non–low-income subsidy groups.

Treatment with immunomodulatory drugs was associated with a reduced risk of emergency department visits (P = .012 for non–low-income subsidy patients and P = .004 for low-income subsidy recipients) and hospitalizations (P = .046 and P < .001) compared with first-line parenteral bortezomib (Velcade) treatment without immunomodulatory drugs. No differences in these outcomes were observed between immunomodulatory drug use and combination use of bortezomib and immunomodulatory drugs.

One-year overall survival and cumulative Medicare costs were similar between those receiving immunomodulatory drug therapy and those receiving bortezomib alone. Medicare costs were significantly higher with combination treatment vs bortezomib alone for low-income subsidy nonrecipients (P < 001) but not low-income subsidy recipients (P = .58).

The investigators concluded: “Medicare beneficiaries with myeloma who do not receive [low-income subsidies] face a substantial financial barrier to accessing orally administered anticancer therapy, warranting urgent attention from policymakers. Limiting out-of-pocket costs for expensive anticancer drugs like the [immunomodulatory drugs] may improve access to oral therapy for patients with myeloma.”

The study was supported by the American Cancer Society and an American Society of Hematology Research Scholar Grant.

Adam J. Olszewski, MD, of Rhode Island Hospital, Brown University, is the corresponding author of the Journal of Clinical Oncology article.

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®.