Treating Financial Toxicity: Subsidies Improve Access to Oral Therapies for Medicare Beneficiaries With Myeloma

Low-income subsidies (LIS), which are available to Medicare beneficiaries who earn less than 150 percent of the federal poverty level, alleviate the financial burden for patients with myeloma taking immunomodulatory drugs (IMiDs), saving them $5,000 in the first year alone, according to a study published in the Journal of Clinical Oncology.

LIS also increase patients’ access to this class of myeloma therapies, explained Adam J. Olszewski, MD, from the Rhode Island Hospital, and co-authors. In their analysis of IMiD costs, refill patterns, and health outcomes among Medicare Part D beneficiaries who were and were not eligible to receive LIS, the authors found “an increased use of IMiDs among low-income subsidy recipients with multiple myeloma (MM), [which] suggests that the LIS may have facilitated access to IMiDs.”

Out-of-pocket expenses (determined by a review of health-care records and Medicare Part B data) also differed dramatically: Patients receiving LIS paid $3 out-of-pocket for their first IMiD prescription (including thalidomide and lenalidomide), compared with $3,178 for those who did not receive LIS.

The researchers used the Surveillance, Epidemiology, and End Results (SEER)–Medicare database to identify patients diagnosed with MM between 2007 and 2011. Patients were included in the analysis if they were continuously enrolled in Medicare Parts A and B from 12 months prior to diagnosis and onward, were not participating in a managed-care plan, and had Medicare Part D coverage at diagnosis. Patients who had prescription coverage provided by other sources or no creditable coverage were excluded.

Of the 3,038 beneficiaries included, 2,059 received LIS (median age = 76 years; range = 71-81 years) and 979 did not (median age = 76 years; range = 71-82 years). All patients initiated chemotherapy a median of 1.1 months (range = 0.7-1.9 months) after MM diagnosis.

A total of 1,250 patients (41.1%) received an IMiD as part of firstline therapy (defined as drugs administered during the first 60 days of treatment): 42 percent in the LIS group and 41 percent in the non-LIS group. Univariate analysis determined that patients receiving IMiDs were more likely to be younger, have better performance status, and have fewer comorbidities.

On average, patients received six IMiD prescriptions during the first year of treatment (range = 3-11 prescriptions), at a median gross drug cost of $39,250 (range = $15,145-70,133). The gross drug cost for the first prescription alone was $6,927 (range = $4,125-7,522).

The median duration of firstline therapy was 7.6 months (range not provided), with 38 percent of patients continuing treatment for more than 12 months.

“We found that for Part D beneficiaries without LIS, the use of IMiDs entailed median out-of-pocket expenses of [more than] $5,600 in the first year, corresponding to 23 percent of their median yearly income ($24,150 in 2014),” the authors wrote.

  • Median patient cost-sharing for those with and without LIS were:
  • First prescription: $3 (range = $3-6) and $3,178 (range = $2,079-4,018)
  • First year of therapy: $6 (range = $3-10) and $5,623 (interquartile range = $3,882-9,437)

Patients receiving LIS had significantly more comorbidities, worse performance status, and less favorable socioeconomic characteristics.

Older patients (75-84 years) receiving LIS had a 32 percent higher probability of being treated with an IMiD, compared with non-recipients (95% CI 16-47; p<0.001).

Receipt of LIS also appeared to lower the likelihood of prolonged (>45 days) delays between IMiD prescriptions (relative risk = 0.54; 95% CI 0.32-0.92; p value not reported), regardless of patient age, but not the duration of IMiD therapy (hazard ratio = 1.02; 95% CI 0.87-1.20; p value not reported).

When the authors compared health-care resource use between patients in the SEER cohort treated with IMiDs and a reference group of patients treated with bortezomib, they found that IMiD use was associated with a significantly lower incidence of visits to the emergency department, regardless of whether patients received LIS (p=0.012 for LIS non-recipients and p=0.004 for LIS recipients), but not for patients treated with bortezomib (p=0.17 and p=0.72, respectively). The same was true for the frequency of hospitalizations among IMiD-treated patients (p=0.46 for LIS non-recipients and p<0.001 for LIS recipients), but again, not for bortezomib-treated patients (p=0.54 and p=0.60).

Overall survival at one year was similar between patients who received IMiDs and those who received bortezomib without IMiDs (71.4% and 75.1%), as well as those who received a combination of both (81.3%).

“The escalating cost of novel anti-cancer medications has raised concerns about financial toxicity for patients and health-care system alike,” the authors concluded. “Subsidies alleviating patients’ financial burden for orally administered chemotherapy may significantly influence treatment selection among certain beneficiaries with MM and their subsequent health outcomes.”

The study is limited by its use of database information, which does not discern reasons for prescription delays or whether out-of-pocket costs were paid by beneficiaries or tertiary sources. The researchers also excluded patients enrolled on managed-care plans and those with alternative prescription coverage, so the results may not be generalizable to the entire patient population.

The study was supported by the American Cancer Society and an American Society of Hematology Scholar Award.

The authors report no financial conflicts.


Olszewski AJ, Dusetzina SB, Eaton CB. Subsidies for oral chemotherapy and use of immunomodulatory drugs among Medicare beneficiaries with myeloma. J Clin Oncol. 2017 May 25. [Epub ahead of print]