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Oncologists and their patients are facing a number of significant changes in health insurance coverage and in private financial assistance programs, primarily resulting from the implementation of the Medicare Part D prescription drug program. The Part D benefit has been described as the most substantial change in Medicare since the program began 40 years ago. By providing coverage for oral drugs, the benefit may provide important new coverage for cancer patients who are increasingly utilizing oral cancer therapies and continue to benefit from supportive care drugs that are generally oral medications. However, decisions about enrollment in Part D are highly individualized. Beneficiaries, with the assistance of family members, friends, and organizations serving seniors, are analyzing their own financial situation and utilization of prescription drugs to determine the best enrollment option.
The implementation of Medicare Part D will have an impact on existing financial assistance programs that are run by independent nonprofit agencies. Existing programs offer general copayment assistance grants and grants for other cancer-related expenses to patients who are struggling financially, even though they have insurance. (Some of these agencies also have funds to help the uninsured.) These independent nonprofit agencies may also be called on to administer programs that will assist Medicare patients with copayments under Medicare Part D. These independent programs may replace manufacturer-sponsored patient assistance programs, which will face limits in how they may offer assistance to Part D beneficiaries.
This article will introduce the existing copayment foundations and how they work. Its goal is to help oncologists to guide patients who need financial support so that those patients can receive support in a timely fashion. It will briefly outline the kinds of assistance offered by these programs, and ways that oncologists can help their patients keep available resources. Finally, we'll discuss how such programs may be affected when Medicare Part D takes effect in January 2006.
“Money is a taboo subject which nobody wants to talk about. Oncologists are focused on curing the disease or helping people manage their illness. And patients are really reluctant to bring these issues up with the doctor themselves. They don't want to be rejected,” explains Jane Levy, the director of patient assistance programs at CancerCare, a prominent, nonprofit patient service agency. She strongly advises that oncologists overcome the taboo.
She suggests that they institute the routine practice of having administrative or billing staff person engage new patients in detailed financial discussions. They should review expected costs of care, resources available to the patient, and ways to address any potential shortfall in funds. Staff collecting initial insurance information can then talk to patients about programs that can help them with costs beyond their means.
Levy emphasizes the value of having this conversation early in the treatment process. “If the medical staff is matter of fact about money issues, then patients feel more comfortable. People are diagnosed with cancer and then they have to stop working. Their income goes down at the same time [that their health care and related costs increase],” says Levy. “The patients wind up in over their heads, and the doctors' offices are sending all these bills to collection and it becomes a crisis.”
The crisis, which might have been avoided through early discussion and action, may be both fiscal and clinical. Today, she says, the potential for noncompliance brought on by money issues is greater than ever. “We see patients trying to stretch out their medications all the time,” Levy says. “They cut their pills in half or they skip them or they don't take the pain medicine.”
“The first step in helping patients is for oncologists and their staffs to be aware of the programs themselves,” advises Beth Darnley, chief program officer with the Patient Advocate Foundation. “Stay abreast of the ones that are available and designate someone on your staff—a social worker, billing clerk, or nurse—to keep a list of the assistance programs and their contact numbers.”
Organizations that offer copayment (and, at times, other financial assistance) help patients with certain diagnoses. The lists of these diagnoses for each organization may change over time. Diagnoses are added and dropped as the nonprofits generate funds to channel into different diseases.
We include our list of noprofit agencies involved in distributing grants for copayment assistance as Table 1. This list is likely to change over time, but is a starting point for your office staff to have available for their use in counseling patients. These organizations provide grants to insured patients with proven needs. Their criteria for eligibility vary, as do the kinds of funding that they offer. The HealthWell Foundation, for instance, requires that a patient's household income be no greater than 300% to 400% of the federal poverty guidelines for the patient to be eligible (with some allowances made for certain high-cost regions).
The Patient Advocate Foundation awards grants of $2,500 per 12-month period for pharmaceutical copayments. Award recipients can reapply for those 12-month grants on an annual basis.
“We have only two qualifiers,” says Darnley, “income and disease category. The patient doesn't have to fill out lengthy forms. The patient and the doctor sign their portion of the application verifying the diagnosis and the prescriptions. Then the patient can be approved. Our usual turnaround time is 5 business days. If the application is sent by fax, we can sometimes approve it the same day.”
In addition to the four significant sources of copayment assistance listed in Table 1, CancerCare, a New York–based patient-assistance organization, provides some copay grants, but that activity is not their main focus. CancerCare helps both insured and uninsured patients by providing limited financial assistance and services, such as support group referrals and education. Financial support is generally focused on helping patients finance transportation, home care, child care, and other expenses that arise when a person has cancer. In 2004, CancerCare distributed grants with a net value of about $2.3 million, supporting 9,833 patients. Its programs provide help of various sorts to more than 90,000 people each year. CancerCare does have small grants to cover oral medications for breast cancer patients. It is also running a special program for ASCO to help cancer patients affected by Hurricanes Katrina and Rita.
Looking ahead to the implementation of the Medicare Part D prescription drug benefit, Levy says, “Part D will definitely help people who are paying a lot out of pocket now for medications. I have no doubt about it. How much it helps will depend on what plans are available in their states and what they can afford. Cancer drugs are very, very expensive,” she notes. “Even if the plan pays the first $2,500, then the patients have to pay the rest until they reach the next level,” which is $5,100 for prescription drugs.
Regardless of the impact of Part D, which remains to be seen as the program unfolds, Levy says that it is an unfortunate reality that organizations such as her own, which offer grants to patients of all ages, “will always have enough customers.”
Many patients who are now receiving free or low-cost drugs from pharmaceutical manufacturers through patient assistance programs (PAPs) are likely to experience changes in how they receive assistance. Companies are reviewing existing PAPs to ensure their efforts are consistent with guidance published by the Department of Health and Human Services Office of the Inspector General (OIG) on November 7, 2005, in the report. The OIG recommended that pharmaceutical companies, as an alternative to direct patient support, make cash donations for patient assistance to bona fide independent charities. Because there are relatively few independent organizations offering copay assistance, these groups may be seriously taxed if they experience dramatic increases in responsibility for assistance programs to Part D enrollees. The November 2005 report is the rationale for the OIG decision. “Patient Assistance Programs for Medicare Part D Enrollees.”
OIG stated that, once Part D takes effect, drug manufacturers can “donate to bona fide independent charity PAPs, provided that adequate safeguards exist.” That is, “the independent charity PAP must not function as a conduit for payments by the pharmaceutical manufacturer to patients and must not impermissibly influence beneficiaries' drug choices.” As with all matters pertaining to the Part D benefit, the impact of the OIG ruling on drug company PAPs will really be known only once the program becomes operational.