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Brief Report
November 9, 2017

Out-of-Pocket and Health Care Spending Changes for Patients Using Orally Administered Anticancer Therapy After Adoption of State Parity Laws

Author Affiliations
  • 1Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
  • 2Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
  • 3University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill
  • 4Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill
  • 5Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
  • 6Division of Hematology and Oncology, University of North Carolina at Chapel Hill School of Medicine
  • 7Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Oncol. Published online November 9, 2017. doi:10.1001/jamaoncol.2017.3598
Key Points

Question  How have state parity laws regarding coverage for orally administered chemotherapy drugs changed their use, out-of-pocket spending, and total health plan expenses?

Findings  In this analysis of health claims data from 3 nationwide insurers involving 63 780 adults, state parity laws appeared to reduce monthly spending on prescription fills at the lower end of the out-of-pocket spending distribution but appeared to increase spending for prescription fills with the highest out-of-pocket spending. Parity laws were not associated with changes in 6-month total health care spending.

Meaning  Although oral chemotherapy parity laws have been widely adopted by states, these laws have not consistently reduced out-of-pocket spending for orally administered anticancer medications.


Importance  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.

Objective  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.

Exposures  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).

Main Outcomes and Measures  Oral anticancer medication use, out-of-pocket spending, and total health care spending.

Results  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.

Conclusions and Relevance  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.