Health plans and pharmacy benefit managers should find ways to support treatment decisions made by cancer care providers and their patients rather than limiting where, how, and which drugs can be administered.
Background: Across practices and programs that are both academic and community based, members of the Association of Community Cancer Centers (ACCC) provide high-quality, patient-centric care to approximately 65 percent of the nation’s patients with cancer. Given significant variability in the presentation and treatment of cancer, it is important that care plans established by providers are highly individualized to meet their patients’ specific needs and challenges. However, health plans are increasingly restricting provider and patient options when deciding where patients can receive cancer care, how cancer drugs can be dispensed, and even which drugs will ultimately be covered.
ACCC believes that to improve the accessibility and affordability of therapeutic options for patients while maintaining clinical quality and safety standards, the following principles should be considered:
- Health plans should not restrict their drug formularies to cover only a single biosimilar or oral oncolytic product for a given diagnosis or therapeutic area. This form of exclusionary contracting creates administrative and operational challenges for providers when multiple health plans each require the use of a different drug. Moreover, while the selection of a single preferred product may be financially advantageous for the health plan, this practice creates financial toxicity for patients when less expensive drugs are available but not covered by their insurance.
- Cancer care providers should not be required to accept or administer drugs supplied via white or brown bagging, processes that require medications to be shipped from specialty pharmacies dictated by the patient’s health plan to their provider’s office or to the patient’s home, respectively. These practices can create safety issues for patients, lead to treatment delays, and place unnecessary administrative burden on both providers and patients. Providers are better able to deliver high-quality, personalized care when they are empowered to manage all facets of cancer treatment from drug procurement through administration.
- While in some cases patient access challenges may be overcome by shifting infusion therapy to alternate sites of care or the patient’s home, these alternatives may be cost prohibitive and/or raise safety concerns for the patient. For this reason, site of service decisions should not be mandated by the patient’s health plan and should result from shared decision-making between the patient and their provider based on their unique circumstances.
- Patients should not be steered away from cancer programs and practices that refuse to accept white- or brown-bagged products or that refuse to move infusion patients to a different site of care based on patient safety and affordability concerns.
Please visit accc-cancer.org for additional policy and advocacy information for the cancer care community.
Request: Health plans and pharmacy benefit managers should find ways to support treatment decisions made by cancer care providers and their patients rather than limiting where, how, and which drugs can be administered. ACCC believes that providers are able to deliver the highest quality, safest, and most affordable care when these treatment choices reflect a patient’s individual circumstances and barriers to care.
