Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill.
Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill.
JAMA Oncol. 2018 Jun 14;4(6):e173598. doi: 10.1001/jamaoncol.2017.3598.
Oral anticancer medications are increasingly important but costly treatment options for patients with cancer. By early 2017, 43 states and Washington, DC, had passed laws to ensure patients with private insurance enrolled in fully insured health plans pay no more for anticancer medications administered by mouth than anticancer medications administered by infusion. Federal legislation regarding this issue is currently pending. Despite their rapid acceptance, the changes associated with state adoption of oral chemotherapy parity laws have not been described.
To estimate changes in oral anticancer medication use, out-of-pocket spending, and health plan spending associated with oral chemotherapy parity law adoption.
DESIGN, SETTING, AND PARTICIPANTS: Analysis of administrative health plan claims data from 2008-2012 for 3 large nationwide insurers aggregated by the Health Care Cost Institute. Data analysis was first completed in 2015 and updated in 2017. The study population included 63 780 adults living in 1 of 16 states that passed parity laws during the study period and who received anticancer drug treatment for which orally administered treatment options were available. Study analysis used a difference-in-differences approach.
Time period before and after adoption of state parity laws, controlling for whether the patient was enrolled in a plan subject to parity (fully insured) or not (self-funded, exempt via the Employee Retirement Income Security Act).
Oral anticancer medication use, out-of-pocket spending, and total health care spending.
Of the 63 780 adults aged 18 through 64 years, 51.4% participated in fully insured plans and 48.6% in self-funded plans (57.2% were women; 76.8% were aged 45 to 64 years). The use of oral anticancer medication treatment as a proportion of all anticancer treatment increased from 18% to 22% (adjusted difference-in-differences risk ratio [aDDRR], 1.04; 95% CI, 0.96-1.13; P = .34) comparing months before vs after parity. In plans subject to parity laws, the proportion of prescription fills for orally administered therapy without copayment increased from 15.0% to 53.0%, more than double the increase (12.3%-18.0%) in plans not subject to parity (P < .001). The proportion of patients with out-of-pocket spending of more than $100 per month increased from 8.4% to 11.1% compared with a slight decline from 12.0% to 11.7% in plans not subject to parity (P = .004). In plans subject to parity laws, estimated monthly out-of-pocket spending decreased by $19.44 at the 25th percentile, by $32.13 at the 50th percentile, and by $10.83 at the 75th percentile but increased at the 90th ($37.19) and 95th ($143.25) percentiles after parity (all P < .001, controlling for changes in plans not subject to parity). Parity laws did not increase 6-month total spending for users of any anticancer therapy or for users of oral anticancer therapy alone.
While oral chemotherapy parity laws modestly improved financial protection for many patients without increasing total health care spending, these laws alone may be insufficient to ensure that patients are protected from high out-of-pocket medication costs.
重要性： 口服抗癌药物对于癌症患者来说是越来越重要但昂贵的治疗选择。到 2017 年初，43 个州和华盛顿特区已经通过法律，确保私人保险患者在全额保险健康计划中支付的口服抗癌药物费用不超过输注的抗癌药物费用。关于这个问题的联邦立法目前正在等待审议。尽管这些法律迅速得到认可，但与州政府采用口服化疗平价法相关的变化尚未得到描述。
目的： 估计与口服化疗平价法采用相关的口服抗癌药物使用、自付费用和健康计划支出的变化。
设计、地点和参与者： 对 2008 年至 2012 年期间来自 3 家全国性保险公司的行政健康计划索赔数据进行分析，由医疗保健成本研究所汇总。数据分析于 2015 年首次完成，并于 2017 年更新。研究人群包括 16 个州的 63780 名成年人，他们在研究期间接受了抗癌药物治疗，并且有口服治疗选择。研究分析采用了差异中的差异方法。
暴露因素： 在州平价法通过前后的时间，同时控制患者是否参加平价计划（全额保险）或不参加平价计划（自我保险，根据《员工退休收入保障法》豁免）。
主要结果和措施： 口服抗癌药物的使用、自付费用和总医疗费用。
结果： 在 63780 名 18 岁至 64 岁的成年人中，51.4%参加了全额保险计划，48.6%参加了自我保险计划（57.2%为女性；76.8%为 45 至 64 岁）。口服抗癌药物治疗作为所有抗癌治疗的比例从 18%增加到 22%（调整后的差异中的差异风险比[aDDRR]，1.04；95%CI，0.96-1.13；P=0.34），与平价法通过前后的月份相比。在受平价法约束的计划中，无共付额的口服治疗处方比例从 15.0%增加到 53.0%，增幅超过不受平价法约束的计划（12.3%-18.0%）的两倍以上（P<0.001）。每月自付费用超过 100 美元的患者比例从 8.4%增加到 11.1%，而不受平价法约束的计划则略有下降，从 12.0%降至 11.7%（P=0.004）。在受平价法约束的计划中，每月自付费用在第 25 百分位数时下降了 19.44 美元，在第 50 百分位数时下降了 32.13 美元，在第 75 百分位数时下降了 10.83 美元，但在第 90 百分位数（37.19 美元）和第 95 百分位数（143.25 美元）时增加，所有这些变化在平价法通过后均具有统计学意义（所有 P<0.001，同时控制不受平价法约束的计划变化）。平价法并没有增加任何抗癌治疗或单独使用口服抗癌治疗的患者的 6 个月总支出。
结论和相关性： 虽然口服化疗平价法在不增加总体医疗支出的情况下，适度改善了许多患者的经济保障，但仅靠这些法律可能不足以确保患者免受高昂的自付药物费用的影响。
