Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee.
Vanderbilt-Ingram Cancer Center, Nashville, Tennessee.
JAMA Health Forum. 2021 May 28;2(5):e210673. doi: 10.1001/jamahealthforum.2021.0673. eCollection 2021 May.
By 2020, nearly all states had adopted oncology parity laws in the US, ensuring that patients in fully insured private health plans pay no more for orally administered anticancer medications (OAMs) than infused therapies. Between 2013 and mid-2017, 11 states implemented parity with out-of-pocket spending caps, which may further reduce patient out-of-pocket spending.
To compare OAM uptake and out-of-pocket and health plan spending on OAMs in states with parity with and without spending caps, as well as to assess out-of-pocket spending for caps that apply predeductible vs postdeductible.
This cohort study analyzed OAM users enrolled in commercial health plans offered by Aetna, Humana, and United Healthcare in the US from 2011 to 2017, aggregated by the Health Care Cost Institute, using difference-in-difference-in-differences (DDD) analysis. Data analysis was conducted between June and August 2020.
Time (before vs after parity), whether the state parity law included an out-of-pocket spending cap, and whether the plan was fully insured (subject to parity) or self-funded (not subject to parity). Among states with caps, out-of-pocket spending was also compared by whether the cap was applied predeductible and postdeductible vs only postdeductible.
Monthly OAM prescription fills per 100 000 enrollees, per-OAM prescription-fill out-of-pocket spending, and annual per-user health plan spending on OAMs.
In this study of 23 states (11 with caps and 12 without) and 207 579 OAM prescription fills, caps were associated with a modest increase in OAM use (DDD, 7.40 [95% CI, 3.41-11.39] per 100 000 enrollees). There was no difference in mean out-of-pocket spending comparing fully insured and self-funded enrollees in states with vs without caps (DDD, -$17 [95% CI, -$57 to $24), but caps were associated with lower spending among OAM users in the 95th percentile of out-of-pocket spending by $831 (95% CI, -$871 to -$791) per OAM prescription fill. Caps applied predeductible were associated with greater out-of-pocket savings relative to caps applied only postdeductible. This included per-OAM prescription-fill savings at the 75th, 90th, and 95th percentiles. Postparity, mean annual spending on OAMs among users was $113 589 in states without caps and $102 252 in states with caps, with no differences between groups (DDD, $9799 [95% CI, -$4230 to $23 829).
In this cohort study, among states adopting oncology parity laws between 2013 and 2017, mean out-of-pocket spending per OAM prescription fill and mean health plan spending among OAM users was similar in states with and without caps. However, enrollees in states with parity plus out-of-pocket caps had greater reductions in out-of-pocket spending among the highest spenders. Caps may offer improved financial protection for the highest spenders without increasing mean health plan spending on OAMs.
到 2020 年，美国几乎所有州都通过了肿瘤学平价法，确保完全受私人健康保险计划保障的患者在口服抗癌药物（OAMs）上的支出不比输注疗法多。在 2013 年至 2017 年年中期间，11 个州实施了与自付支出上限的平价，这可能进一步降低患者的自付支出。
比较有和没有支出上限的州的 OAM 使用率以及 OAM 的自付和健康计划支出，并评估适用于预扣除和扣除后自付支出上限的自付支出。
设计、设置和参与者：这项队列研究分析了 2011 年至 2017 年期间，美国 Aetna、Humana 和 United Healthcare 商业健康计划中口服抗癌药物使用者的情况，这些数据由健康成本协会汇总，使用差异中的差异分析。数据分析于 2020 年 6 月至 8 月进行。
时间（平价前 vs 平价后）、州平价法是否包括自付支出上限以及计划是否完全受保险（受平价限制）或自我资助（不受平价限制）。在有上限的州中，还比较了扣除前和扣除后的支出上限与仅扣除后的支出上限之间的自付支出。
每 100000 名参保者每月 OAM 处方数、每 OAM 处方数的自付支出和每位用户 OAM 的年度健康计划支出。
在这项研究中，23 个州（11 个有上限，12 个没有）和 207579 个 OAM 处方中，上限与 OAM 使用的适度增加相关（DDD，每 100000 名参保者增加 7.40 [95%CI，3.41-11.39]）。在有和没有上限的州中，完全保险和自我保险的参保者之间的平均自付支出没有差异（DDD，-$17 [95%CI，-$57 至 -$24），但上限与自付支出前 95%的 OAM 使用者的支出较低，每 OAM 处方减少 831 美元（95%CI，-$871 至 -$791）。与仅扣除后支出上限相比，扣除前支出上限与更大的自付节省相关。这包括 75%、90%和 95%的 OAM 处方节省。平价后，无上限州的 OAM 用户年平均支出为 113589 美元，有上限州为 102252 美元，两组之间没有差异（DDD，$9799 [95%CI，-$4230 至 -$23829）。
在这项队列研究中，在 2013 年至 2017 年期间采用肿瘤学平价法的州中，有和没有上限的州中，每 OAM 处方的自付支出和 OAM 用户的平均健康计划支出相似。然而，在有平价加自付支出上限的州中，自付支出最高的患者的自付支出降幅更大。上限可能为自付支出最高的患者提供更好的财务保护，而不会增加 OAM 的平均健康计划支出。
