Then and Now: The Financial Impact of Providing Outpatient Antineoplastic Medications at the VANTHCS

In 2003, a retrospective study of VANTHCS Hematology/ Oncology referrals showed 4.5% of 1,038 referrals that year were requests for oral antineoplastic medications that patients could not afford through their outside oncologists. Since then, the field of cancer drug development has expanded dramatically; yet the cost of these drugs remains staggering. The hypothesis was that the proliferation of these new, expensive anticancer medications led to an increase in referrals to VANTHCS Hematology/Oncology. This study sought to determine if referrals had increased since 2003 and to estimate these referrals’ economic impact. All new consults received from 1/2015-12/2015 were abstracted. 1,416 outpatient consults were reviewed for medication requested, disease, age, race, sex, location, and insurance. 1.8% of these referrals was specifically to obtain oral chemotherapy. This is a substantial decrease from 4.5% in 2013. However, 5.6% of total referrals in 2015 were veterans with private oncologists presenting to the VANTHCS because of cost. Of these 79 patients, 26 (1.8% of all consults) requested oral chemotherapy, 17 (1.2%) requested intravenous chemotherapy, and 36 (2.5%) requested transfer of all oncology care. One possible explanation for the decrease in oral antineoplastic
requests since 2003 is the 2006 implementation of Medicare Part D. Evidence to support this program’s role in declining requests is that two-thirds of veterans presenting because of cost in 2015 were not enrolled in Medicare Part D. Even with Medicare Part D, veterans still face a significant cost burden and continue to present for assistance. While the total number of referrals for oral chemotherapy has declined, the cost of providing these medications merits attention. Of the 15 different oral neoplastic medications requested in 2015 by veterans with private oncologists, 10 cost over $3,000 per month per patient. As an example, 4 patients requested and were approved for lenalidomide. Treating these 4 patients cost the VA over $22,000 per month. Thus, though the number of patients is small, the economic impact remains significant.