Tag Archives: oral parity

Oral Parity: When Modern Medicine Outpaces Policy

By Leah Ralph, Director of Health Policy, ACCC

PillsACCC has been a longtime champion of oral parity, the legislative effort to equalize patient cost sharing for intravenous (IV) and oral chemotherapy drugs.

Oral oncolytics can offer a better quality of life for patients undergoing chemotherapy treatment, including less travel time, fewer work absences, often fewer side effects, and the convenience and comfort of at-home administration. For some cancer patients, an oral anti-cancer medication is the only option for treatment. Yet insurance coverage has not kept pace with medical innovation. Outdated insurance benefit designs continue to cover oral medications under the pharmacy benefit, which often means high, burdensome out-of-pocket costs for patients. (Traditional IV chemotherapy is covered under a plan’s medical benefit, resulting in minimal co-pays or no cost for patients.) This coverage disparity creates financial burdens for patients prescribed an oral anti-cancer medicine, leaving them less likely to adhere to treatment and often unable to fill their prescription. The number one reason a patient does not take his or her medication appropriately is cost. According to a 2011 study published in the Journal of Oncology Practice and the American Journal of Managed Care, 10 percent of cancer patients failed to fill their initial prescriptions for oral anticancer medications due to high out-of-pocket costs.

Progress at the State Level

We’ve come a long way in terms of state law. To date, 40 states plus the District of Columbia have passed oral parity legislation. These laws are not a mandate to cover oral chemotherapy, but rather require that if an insurance plan covers chemotherapy treatment, a patient’s out-of-pocket costs must be the same, regardless of how the therapy is administered. As a member of the State Patients Equal Access Coalition (SPEAC), ACCC has partnered with several state oncology societies—including Virginia, West Virginia, and Arizona in recent years—to pass oral parity laws, and this year we’re focusing our efforts on Tennessee and South Carolina. (If you are a provider in either of these states, and you’d like to be an advocate, email ACCC Director of Health Policy, Leah Ralph. ACCC participated in this new SPEAC video that helps to tell the oral parity story from the patient’s perspective.

Why Federal Legislation is Necessary

And even though a majority of states have now passed state-level oral parity legislation, federal legislation is still needed. A federal law would ensure that new cost-sharing restrictions are implemented consistently across the country, and that plans that fall outside state regulation, such as those covered under the federal ERISA law (usually large, multi-state health plans), must comply with the same equitable coverage requirements. In September, an ACCC member spoke at a Congressional briefing on the Cancer Drug Coverage Parity Act of 2015 (S.1566/H.R.2739), helping gain critical momentum to move the bill forward.

In a few weeks, at ACCC 2016 Capitol Hill Day on March 2, ACCC members will be walking the halls of Congress to talk with legislators about the importance of this bill to cancer patients and the providers who care for them.

ACCC encourages members to join our efforts, and continue to monitor opportunities to weigh in with your state and federal legislators. For more on this issue, look for an upcoming article to be published in the March/April Oncology Issues, “Exploring the Issue of Cancer Drug Parity.”



ACCC on Capitol Hill

DSC_0545by Amanda Patton, ACCC Communications

ACCC’s 41st Annual Meeting, CANCERSCAPE, kicked off on March 16 with Capitol Hill Day. ACCC members from across the country fanned out across the Capitol for more than 70 scheduled meetings with legislators and key staff members from both the House and Senate.

With the current Sustainable Growth Rate (SGR) patch set to expire March 31, the timing was ripe for these advocates to speak up for a permanent fix to the SGR.

First time ACCC Hill Day participant Linda Gascoyne, patient advocate for medical oncology, East Maine Medical Center in Brewer, Maine, spent the day with the Maine delegation that met with Senator Susan Collins on Monday, afternoon. “I found her [Senator Collins] to be very empathetic as she listened and learned about what we were asking [from Congress],” Ms. Gascoyne said. In addition to the SGR, the Maine delegation talked with Senator Collins about the need for federal oral parity legislation and elimination of the prompt pay discount from the ASP calculation.

Donna Sulsenti, practice manager, South Shore Hematology Oncology and president of HOMNY was part of the New York delegation that had visits with four congressional offices. “It was extremely interesting speaking about issues with our legislators and getting something accomplished,” she said. She also finds it “satisfying to know that ACCC is working for us.”

Another first time ACCC Hill Day participant Monica Cfarku, nurse manager, Oregon Health & Science University, Knight Cancer Institute, said she “learned a lot” from her meetings with hill staff. In turn, she found staff engaged on the issues and interested in learning from her. “I felt like I offered them a different perspective as someone on the frontline of care delivery.” In fact, staff from a congressional office invited her to return later in the week to share more of her perspective.

Stay tuned for more from ACCC’s Annual Meeting, Cancerscape underway in Arlington, Va. Follow us on Twitter at #cancerscape15.

Ringing in the New Year

US Capitolby Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

The last few months have brought big changes to Washington, D.C. We will ring in the New Year with both chambers of Congress under GOP control, which means the parties are reorganizing and, importantly, the legislative agenda is shifting. While it’s still anyone’s guess whether new leadership will mean less political infighting in 2015, issues like trade, energy, and tax reform are early contenders for potential areas of compromise next year.

The ACA (Affordable Care Act) will also make the top of the political agenda: starting in January, you can count on Republicans to look for every opportunity to take the legs out from under President Obama’s signature achievement. Although full repeal is unlikely, as it would face an all-but-guaranteed presidential veto, expect the new majority to focus their efforts on introducing a series of stand-alone bills targeting the most unpopular provisions of the law.

Predicting the fate of non-ACA healthcare legislation is a tougher call. On the one hand, healthcare fatigue still looms large among legislators, making issues like a long-term fix to the Sustainable Growth Rate (SGR), oral parity, and sequestration more of an uphill climb. On the other hand, new leadership, a renewed vow to work across the aisle, and public dissatisfaction with the status quo are bringing new energy to Congress.

Will 2015 Bring a Permanent SGR Fix?

In 2014 we saw what was arguably the best opportunity in years to finally fix the fundamentally flawed SGR formula. Congress came to agreement on a bipartisan bill that had a relatively low price tag, but in the end could not reach consensus on how to pay for the fix. As a result, the bill never came to a vote and will need to be reintroduced in the new Congress. Still the fact that Congress achieved consensus on policy is a promising sign for 2015. We have now weathered seventeen (17!) “doc fix” patches that, if added together, cost far more than the comprehensive approach lawmakers are considering today. This year’s ACCC Capitol Hill Day is scheduled for March 16, so we will be visiting with our legislators just weeks before the current “doc fix” expires on March 31.

Will We See Federal Oral Parity Legislation?

Passing a national oral parity law continues to be a top priority for ACCC membership. On the state level, oral parity efforts are gaining momentum. To date, 34 states and D.C. have enacted oral parity laws, and several other states are ramping up their grassroots efforts for 2015. Given that an estimated 25 to 35 percent of all oncology therapies in the pipeline will available only in pill form, the need for comprehensive, federal oral parity legislation is increasingly critical to patient access. While state-level legislation remains important, lawmakers need to understand that federal legislation would ensure consistency in oral parity laws across the country and would include plans that fall outside the purview of state regulation.

Will We See Any Relief from the Sequester?

Last year, legislation to exempt cancer drugs from the Medicare sequester gained more than 100 cosponsors. ACCC will be advocating for this legislation to be reintroduced in 2015.

As you can see, 2015 is the year to make your voice heard! Join us for Capitol Hill Day on March 16, and stay for the ACCC 41st Annual Meeting, CANCERSCAPE, which will follow March 17–18 in Crystal City, Va. Read our agenda and register today!

If you have additional questions, or would like to get involved with ACCC advocacy, please contact me at lralph@accc-cancer.org.



ACCC Hill Day Primer—Issue #3: Pass Oral Parity Legislation

by Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC

U.S. Capitol

ACCC’s Capitol Hill Day on March 31 is less than one week away.  ACCCBuzz is featuring a primer series on the key issues ACCC members will be talking about on Capitol Hill. In this third of four installments, we’ll look at the need to pass federal oral parity legislation.

By now you know the issue: oral parity legislation is needed to ensure that patients can afford their oral anti-cancer medications. And you have probably already heard that 29 states have passed oral parity laws requiring insurance companies to cover oral chemotherapies at the same rate they already cover IV-infused medications. Considering that more than half of the states have passed oral parity laws, and that number continues to grow, why is oral parity an advocacy issue for ACCC’s federal Hill Day?

Even though state laws are currently being passed, federal legislation is still required for two important reasons:

  1.        Language of the laws varies across the states and only federal legislation will ensure the same protections for all patients; and
  2.        State laws only impact state-regulated plans.  Federal legislation is needed to cover self-insured plans (ERISA).

Currently, there are bills in both chambers of Congress, just waiting for ACCC advocates to push them forward. HR 1801 in the House has 71 cosponsors, while the newer S 1879 in the Senate only has one cosponsor.  ACCC members, please speak up for this important legislation.

Those of you coming to Washington, D.C., on March 31st for ACCC’s Hill Day will have a chance to explain why this legislation matters in person.

ACCC members who cannot make the trip to D.C. next week can still express support for federal oral parity legislation and ask Congress to pass HR 1801 and S 1879. Visit ACCC’s Legislation Action Center to find out how.

Will you be a cancer care advocate? Learn more about the issues, sign up for Hill Day, and make your voice heard.

Protecting Patient Access: Taking It to the Hill

By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC

U.S. Capitol We’re on the countdown to ACCC’s Capitol Hill Day on March 31. ACCC members who join us will be visiting with congressional staff to speak out on major concerns affecting oncology care. Those on the front lines of cancer care can deliver a powerful, clear message on issues affecting cancer patients and providers. Patient access to care—in particular to anti-cancer medications—is a cross-cutting concern.

Where Things Stand in Congress—Two Bills

Many health insurance plans cover IV chemotherapy, injected anti-cancer medications, and oral anti-cancer drugs differently, causing patients to pay far more out-of-pocket for oral drugs than for IV chemotherapy or injected medications. With the ever rising cost of healthcare, insurers employ various methods to keep costs down, including increasingly shifting the cost of prescription drugs to patients. To help patients afford the life-saving medications they need, Congress has introduced two complementary—if not somewhat confusing—pieces  of legislation: HR 1801 and companion bill S 1879 to lower the cost of prescription oral chemotherapy drugs, and HR 460, to limit cost-sharing requirements for prescription drugs on specialty tiers. Both bills aim to protect cancer patients in different ways.

Here’s a quick side-by-side comparison of the legislation. For ACCC members joining us for Capitol Hill Day, this snapshot can help you prepare for conversations with congressional staff.

Oral Parity (HR  1801/S 1879)

  • Legislation would require insurers to provide coverage for orally administered anti-cancer medication under terms no less favorable than for medication administered intravenously. Insurers may not create parity by raising rates for IV infusions.
  • Focus is on cost-sharing across prescription drug coverage and office visit coverage for anti-cancer medications only.
  • Requirements: A physician must deem the treatment to be medically necessary for treating cancer, and the treatment must be clinically appropriate in terms of type, frequency, and duration.
  • Types of insurance affected: Group  and individual private plans and self-insured group plans regulated by ERISA that cover oral and IV-infused anti-cancer medications.

Specialty Tier (HR  460)

  • Legislation would limit cost-sharing requirements applicable to prescription drugs in a specialty tier to the dollar amount of such requirements applicable to prescription drugs in a non-preferred tier.
  • Focus is on cost-sharing in prescription drug coverage plans and formularies for any specialty-tier drug covered by the plan.
  • Requirements: A health plan that provides coverage for prescription drugs using a cost-sharing structure shall not impose cost-sharing requirements applicable to prescription drugs in a specialty drug tier that exceed the dollar amount of cost sharing for drugs in a non-preferred brand tier.
  • Types of insurance affected: Group and individual private plans that cover prescription drugs and use a formulary or other tiered cost-sharing structure. Bill language is unclear as to whether ERISA plans are affected.

Both bills help protect patient access to affordable prescription drugs. However, because oral parity legislation already has 67 co-sponsors in the House and a companion bill in the Senate, this will most likely move through Congress first. Therefore, ACCC will be advocating for oral parity (HR 1801/S 1879) in both chambers on Hill Day. In addition, we will be talking to our representatives about SGR reform, elimination of cancer drugs from the 2% Medicare sequester, and elimination of the prompt pay discount. Learn more about Hill Day 2014 and register today.