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The Complex Cancer Care Coverage Environment - What is the Role of Legislation? A Case Study from Massachusetts
Christine Leopold1, Rebecca L Haffajee1, Christine Y Lu1
1Christine Leopold, Ph.D., M.Sc., conducted this research while she was a senior research fellow in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She received her Ph.D. from Utrecht University and her Master of Science degree in international healthcare management, economics and policy from Bocconi University. Rebecca L. Haffajee, J.D., Ph.D., M.P.H., is a Policy Researcher at RAND Corporation and an Adjunct Assistant Professor of Health Management and Policy at the University of Michigan School of Public Health. She received her law degree from Harvard Law School and a Master in Public Health degree from Harvard T.H. Chan School of Public Health. She completed her Ph.D. in health policy with a concentration in evaluative science and statistics at Harvard University in 2016. Christine Y. Lu, M.Sc, Ph.D., is an Associate Professor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute and she co-directs the PRecisiOn Medicine Translational Research Center. She received her M.Sc. in biopharmaceuticals and a Ph.D. from the University of New South Wales. Anita K. Wagner, Pharm.D., M.P.H, Dr.P.H., is Associate Professor at the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She serves as the Director of the Harvard Pilgrim Health Care Ethics Program. She received her Master of Public Health degree in international health and Doctor of Public Health degree in epidemiology from the Harvard School of Public Health.
Abstract:
Over the past decades, anti-cancer treatments have evolved rapidly from cytotoxic chemotherapies to targeted therapies including oral targeted medications and injectable immuno-oncology and cell therapies. New anti-cancer medications come to markets at increasingly high prices, and health insurance coverage is crucial for patient access to these therapies. State laws are intended to facilitate insurance coverage of anti-cancer therapies.Using Massachusetts as a case study, we identified five current cancer coverage state laws and interviewed experts on their perceptions of the relevance of the laws and how well they meet the current needs of cancer care given rapid changes in therapies. Interviewees emphasized that cancer therapies, as compared to many other therapeutic areas, are unique because insurance legislation targets their coverage. They identified the oral chemotherapy parity law as contributing to increasing treatment costs in commercial insurance. For commercial insurers, coverage mandates combined with the realities of new cancer medications - including high prices and often limited evidence of efficacy at approval - compound a difficult situation. Respondents recommended policy approaches to address this challenging coverage environment, including the implementation of closed formularies, the use of cost-effectiveness studies to guide coverage decisions, and the application of value-based pricing concepts. Given the evolution of cancer therapeutics, it may be time to evaluate the benefits and challenges of cancer coverage mandates.
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