• Benign Prostatic Hyperplasia
  • Hormone Therapy
  • Genomic Testing
  • Next-Generation Imaging
  • UTUC
  • OAB and Incontinence
  • Genitourinary Cancers
  • Kidney Cancer
  • Men's Health
  • Pediatrics
  • Female Urology
  • Sexual Dysfunction
  • Kidney Stones
  • Urologic Surgery
  • Bladder Cancer
  • Benign Conditions
  • Prostate Cancer

Changes in Legislation for Advanced Prostate Cancer Therapy Reimbursement


Experts in urology share a brief conversation on recent and future legislation for insurance coverage and reimbursement, considering how it may impact their management of prostate cancer.


Paul R. Sieber, MD: That brings us to what Congress [is] going to do in this new Medicare legislation, and Chris, maybe you have some insights into where you think this Inflation Reduction Act is going to go in terms of, in particular, how it’s going to change the landscape for managing all these [patients with] advanced prostate cancer.

Christopher M. Pieczonka, MD: The legislative relief that’s going to happen is not going to make inflation better. More than likely, what it’s going to do is increase utilization of the medicines because we’re going to shift the burden...from patients back onto the federal government, which I think is a good thing as a cancer [care] provider. So my understanding of this is that this changes on a year-over-year basis in a favorable way for patients, at least on the Part D side. So one of the things that happens next year is that on the Part D side, patients end up having coinsurance, and if they eventually get to what’s called catastrophic coverage, they would still be on the hook for 5% of the cost of their drugs, and if you use a combination of medicine, that can be tens of thousands of dollars of...cost, and so 5% of that is still a big number. That goes away I think in 2024. They also decrease the number for the total out-of-pocket costs for the patients, and that’s going to go down in 2025, to a total out-of-pocket cost of $2000...for all of their Part D drugs, for the Eliquises of the world, for all the other stuff.

And so for our [patients with prostate cancer], we’re going to be able to find that that’s going to be easier, and there’ll be less financial toxicity for them. And my understanding of the way that this is going to work is that the patients will be able to pay it off over time so that the money that they would otherwise owe to the federal government is not going to be so front-loaded in the January situation, where it becomes quite a difficult thing for the patient. So I think that we’re going to have patients who are right now opting not to get cancer therapy, oral cancer therapy, who are going to be able to opt back into that because of the [income] that’s going to go back to the federal government. So I think it’s a good thing overall. I don’t think it’s going to control cost as far as that goes because the utilization, in my opinion, will go up.

Paul R. Sieber, MD: I think so, too, and as Richard said, January is always a tough time, and people literally skip medicines until they can...get caught up, and I think if I didn’t have that to worry about, if I can have that spread out over the whole year, my world would definitely change, that’s for darn sure.

Aaron Berger, MD: Certainly we do have a lot of patients who just simply can’t afford their co-pays...and as we’ve all said, that early year $800, $900, $1000 [in] co-pays...those do go away over time once they...meet their cap, and if that cap number is going to be reduced, I think that’ll make it easier for them to get some of the therapies that we would recommend in the standard of care and they should be getting, especially if it’s going to be spaced out throughout the course of the year and not front-loaded in January, [when] everyone’s just finished spending all the money for holiday gifts and things like that. It’s hard to come up with a $1000 copay for your prostate cancer pills right off the bat. So certainly, that will hopefully be beneficial, but I 100% agree with Chris. I think that the pot of money that we have to get these drugs covered and foundation assistance, which already this year has been a total disaster, are not going to get any better, as there [are] new drugs coming out, existing drugs moving up in the timing of when we use these drugs. The indications keep getting earlier and earlier, more combination therapies. So it’s really going to be a persistent challenge. It’s great to have options for prostate cancer, it’s great to have new treatments, but the problem of making them accessible and affordable is already challenging and is unfortunately probably going to become more so.

Paul R. Sieber, MD: Richard?

Richard David, MD, FACS: Well, I don’t know much of the specifics of the Inflation Reduction Act, but I could tell you pretty much when the government gets involved, things get all screwed up. So I think the challenge for us will be in how it gets actually implemented. And if it does, what it’s purported to do—that is reducing some of the financial burden of oral medications on patients—I think that will be great. But I think it’s a question of wait and see what we’re actually going to get.

Paul R. Sieber, MD: I would agree with Chris. If I can have the problem with co-pays go away on my orals, my world would be so much easier. I mean, the day would flow so much more smoothly. And hearing people talk about my angst, I can’t get it, or it wasn’t shipped, and...my foundation support ran out. It would be amazingly positive to not have to deal with that burden. It’s always hanging over our head.

Christopher M. Pieczonka, MD: Well, I mean, it really sucks as a patient. I mean...I have a patient who can’t afford a second-generation antiandrogen. So, I’m using bicalutamide at 150 mg, which [are] data from literally two decades ago. And in the event that this changes and it fared away from a co-pay standpoint, he’ll now be on standard-of-care medicine. So it’s really sad for patients.

Paul R. Sieber, MD: I’ve...had an insurer ask me to give abiraterone in a nonstandard manner to decrease the dosing. And it was an insurer [who] ask[ed] me specifically [whether] would I be amenable to giving a medication with a meal because they think they can get away with it vs a standard dose. And it’s...scary to think that’s where we’re going. But I think the cost is becoming an issue. I mean, prostate cancer spending has gone through the roof, but we’re seeing 4% to 5% new patients [with] metastatic [disease] every year. It’s not going to go away.

Transcript is AI-generated and edited for clarity and readability.

Related Videos
A panel of 4 experts on prostate cancer
A panel of experts on prostate cancer
A panel of 4 experts on prostate cancer
A panel of 4 experts on prostate cancer
A panel of 5 experts on bladder cancer
A panel of 5 experts on bladder cancer
A panel of 4 experts on prostate cancer
A panel of 4 experts on prostate cancer
Related Content
© 2024 MJH Life Sciences

All rights reserved.