Patients covered under Medicare Part D will pay up to 79% less for 10 prescription drugs for chronic conditions, including ibrutinib for chronic lymphocytic leukemia/small lymphocytic lymphoma and other blood cancers, starting on January 1, 2026, the Centers for Medicare and Medicaid Services said. In August 2024, the agency released its final list of lowered drug prices for the 10 treatments selected under the price negotiation program.

Nearly 50% of patients and survivors develop medical debt related to their cancer, with an even higher burden among Black and Hispanic individuals. Patients with medical debt say that their inability to afford treatment or food takes a toll on their mental health, even to the extent that they avoid future health care. The American Cancer Society Cancer Action Network (ACS CAN) shared the new survey data in its April 2024 Survivor Views report.

The journey from cancer diagnosis to treatment with hematopoietic stem cell transplantation (HSCT) is a complex, costly, and multifaceted process influenced by various factors that shape the course of patient care. HSCT is particularly susceptible to racial, socioeconomic, and geographic disparities in access and outcomes, given its specialized nature and limited availability in just about 200 U.S. cancer centers.

A new Biden administration rule released Wednesday aims to streamline the prior authorization process used by insurers to approve medical procedures and treatments. Prior authorization is a common tool used by insurers but much maligned by providers and patients, who say it’s often used to deny provider-recommended care.

For oral anticancer medications that can be stored at room temperature, dispensing unused pills can save individuals up to $1,600 per year, researchers reported in study results published in JAMA Oncology.

If it sounds too good to be true, it probably is. Many employers are beginning to learn that lesson about alternative funding programs, but patients are the ones bearing the brunt of the burden. Oncology nurses have a responsibility to understand that lesson, too—and the power to promote awareness and change. 

The vast majority of patients, nurses, and physicians said that insurer policies and practices are reducing access to medical care, driving up healthcare costs, and increasing clinician burden and burnout, the American Hospital Association reported in survey results released in July 2023.

The BTK inhibitor ibrutinib is one of the first 10 drugs covered under Medicare Part D eligible for price negotiation authorized through the Inflation Reduction Act, the U.S. Department of Health and Human Services (HHS) announced in August 2023. Together, the 10 drugs accounted for 20% of Medicare Part D prescription drug costs during the 12-month period used to identify the initial group of negotiable agents. Medicare enrollees taking the 10 drugs covered under Part D selected for negotiation paid a total of $3.4 billion in out-of-pocket costs for the drugs in 2022.

Individuals at risk for financial toxicity from the high costs of hematologic cancer care reported saving an average of $2,500 when guided by the services of an oncology financial navigation program, researchers reported in the Journal of Oncology Practice.

Alleviating the effects of persistent poverty on cancer outcomes requires building research capacity, fostering cancer prevention research, and promoting the implementation of community-based programs. To enhance the United States’ capacity to do so, the Biden-Harris administration awarded $50 million in June 2023 to create five new Centers for Cancer Control Research in Persistent Poverty Areas that will advance the Cancer Moonshot’s priorities.

In bipartisan, bicameral effort to help older adults save money when choosing a Medicare healthcare plan, Senators Bill Cassidy, MD (R-LA), and Tom Carper (D-DE) and Representatives Earl Blumenauer (D-OR) and Brad Wenstrup, DPM (R-OH), reintroduced the Program of All-Inclusive Care for the Elderly (PACE) Part D Choice Act in the U.S. House of Representatives and U.S. Senate in May 2023. The legislation allows Medicare-only PACE participants to choose between the PACE Part D plan or a standalone Medicare Part D plan without incurring high Part D premiums.

People who live near nuclear weapons testing sites or work with uranium, U.S. Department of Energy employees, and firefighters, victims, and rescue and recovery workers from the September 11, 2001, attacks may be eligible for various government- or employer-funded compensation if they develop cancers because of their exposure to known related carcinogens. The funds can alleviate some of patients’ financial burden of cancer treatment and care and support families’ emotional well-being with a tangible reminder that the cancer is unrelated to any underlying inherited genetic disorder.

Equal reimbursement for oral versus IV anticancer agents—also known as oral parity—has been a legislative priority for ONS since the first bill was introduced in the U.S. Congress eight years ago. Working through ONS’s broad coalitions, ONS members have championed patient access to oral anticancer therapies to the seven remaining states without a similar law on the books. Building on that work, on June 15, 2023, U.S. Senators Tina Smith (D-MN) and Jerry Moran (R-KS) reintroduced the bipartisan Cancer Drug Parity Act to further support that goal.

Health care consumes an inordinate amount of the U.S. gross domestic product at 18.3%. In 2021, healthcare spending increased by 2.7% to $4.3 trillion, equating to $12,914 per person annually. Under that average, prescription medications are the highest expenditure. According to the Centers for Medicare and Medicaid Services, “Retail prescription drug spending increased 7.8% to $378.0 billion in 2021, a faster rate than in 2020 when spending increased by 3.7%. The acceleration in growth was due to an increase in the use of prescription drugs in 2021.” On top of that staggering national economic impact are the personal, emotional, and familial burdens that take a toll on patients and caregivers.

Coming to you from Congress®, we get to know the 2023 ONS President's Award recipient, Heather Ferguson, the founder and executive director of the Lymphedema Advocacy Group. Ferguson had a pivotal role in advocating with ONS for the Lymphedema Treatment Act, which was finally passed into law in December 2022 and improves access to care for patients and survivors.

Despite Americans spending more for health care than other high-income countries, the United States has the highest rates of death for avoidable or treatable conditions, maternal and infant mortality, and suicide, researchers reported in an analysis study published in January 2023 by the Commonwealth Fund.

Between travel time and expenses, missed work hours, and other factors, cancer care visits cost patients more than just a copay. A new study quantified the financial benefits of conducting those visits via telehealth versus in person, with researchers reporting that patients saved more than $150 in expenses and three hours in travel and waiting time per visit by using telehealth. They published their findings in JAMA Network Open.

Almost 11.5 million people signed up for healthcare insurance on HealthCare.gov from November 1–December 15, 2022, President Joe Biden announced in December 2022. Enrollment increased 18% over the same period in 2021. 

The complexity of cancer care may affect patients’ financial toxicity more than we’ve realized. Many patients struggle with the economic burden of out-of-pocket spending for cancer care, including insurance copayments, transportation, and reduced income, as well as their psychological burden of worry and coping with less funds for food and medications. Multimodality treatments, maintenance and ongoing therapies for metastatic disease, and geographic factors such as travel for clinical trials and specialized services or paying for out-of-network care can put patients’ finances in a deeper hole. The adverse implications are significant: decreased quality of life, increased anxiety and depression, lower adherence to prescribed medications and oncology care, and reduced survival.

Sick. Americans are literally sick of the financial burden vulnerable patients endure because of high out-of-pocket, healthcare-related costs. The complicated and convoluted issue has no easy solution.

Mei is a 67-year-old patient who recently underwent an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and tumor debulking. Her surgical specimens were sent for pathology review and germline biomarker testing. Based on the findings, Mei was diagnosed with stage IIIC, high-grade serous epithelial ovarian cancer with a BRCA1 pathogenic germline variant.

Inflating more than 50% since 2017, the annual price of newly launched cancer drugs averages $283,000 in 2022, according to a new report from the office of U.S. Representative Katie Porter (D-CA). Although new drugs for any condition are also seeing record-breaking high prices, the cost of new anticancer therapeutics is 3.7 times higher than that of non-oncology drugs.

Patients with cancer experiencing financial hardship during routine care are nearly 1.5 times more likely to die than those who aren’t, researchers reported in study findings published in JCO Oncology Practice.

The U.S. Department of Health and Human Services, through the Health Resources and Services Administration, awarded more than $5 million in September 2022 to 11 HRSA-funded community health centers to help underserved populations access cancer screenings and early detection services in partnership with National Cancer Institute-designated cancer centers.

Under the Inflation Reduction Act, patients will pay lower premiums for the Medicare Advantage and Medicare Part D prescription drug plans during the 2023 coverage year, the Biden-Harris administration announced in September 2022. People with Medicare prescription drug coverage will also receive better and more affordable benefits, including a $35 cost-sharing limit on covered insulin product and coverage for adult vaccines recommended by the Advisory Committee on Immunization Practices.

Making history as the single largest Navigator organization funding award provided to date, the U.S. Department of Health and Human Services, through the Centers for Medicare and Medicaid Services, invested $98.9 million in grant funding to 59 Navigator organizations in August 2022 to help consumers navigate enrollment and make health coverage more accessible.

The Children’s Health Insurance Program helped drop the percentage of uninsured children from 15% to 3.7% since its authorization by Congress in 1997, according to data from the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services released in celebration of CHIP’s 25th anniversary in August 2022.

Patients with cancer and other healthcare consumers would receive reinforcements in the fight against financial toxicity with new legislation that would “empower the Federal Trade Commission (FTC) to increase drug pricing transparency and hold pharmacy benefit managers (PBMs) accountable for unfair and deceptive practices that drive up the costs of prescription drugs.” U.S. Senators Maria Cantwell (D-WA) and Chuck Grassley (R-IA) introduced the proposed bill in May.

A pandemic is not the time to experiment with Medicaid work requirements, the Biden-Harris administration maintained in April 2022 when it urged officials in Arkansas and New Hampshire to cancel their U.S. Supreme Court hearing appeals regarding the Trump administration orders and send the matter back to the U.S. Department of Health and Human Services (HHS) for further action.

Cancer is one of the top five most expensive healthcare conditions to treat, costing the United States more than $157 billion annually. The payout from patients’ pockets may be even greater, with the cost of cancer medications alone standing at $895 billion per year. But paying for cancer during a pandemic? Even financially secure patients with healthcare coverage are struggling.

As many as 71% of patients with advanced cancer—most of whom have healthcare insurance—experience major financial hardship because of their disease, according to study findings published in the Journal of the National Cancer Institute.

Out-of-pocket prescription drug costs for beneficiaries with Medicare Part D could start to lower with improved price transparency and market competition thanks to a January 2022 proposed rule from the Centers for Medicare and Medicaid Services (CMS). The rule, which would take effect on January 1, 2023, would improve beneficiaries’ experiences with Medicare Advantage and Medicare Part D and work to improve health equity in the programs, according to CMS.

Consumers will more easily find affordable healthcare coverage in 2023, thanks to the Biden-Harris administration’s December 2021 Notice of Benefit and Payment Parameters 2023 Proposed Rule, according to the U.S. Department of Health and Human Services’ (HHS) Centers for Medicare and Medicaid Services (CMS). The rule also improves shopping for healthcare coverage, establishes rules to ensure people have access to care, and advances health equity for consumers purchasing Marketplace coverage.

Advancing equity, justice, and opportunity for Asian American (AA) and Native Hawaiian and Pacific Islander (NHPI) communities in the United States requires an ambitious, whole-of-government agenda, the U.S. Department of Health and Human Services (HHS) announced in December 2021. To drive that agenda, the agency launched the Biden-Harris administration’s White House Initiative on Asian Americans, Native Hawaiians, and Pacific Islanders (WHIAANHPI).

Patients now have protection against unexpected—and often extraordinarily high—medical bills. On January 1, 2022, the Biden-Harris administration’s bipartisan No Surprises Act went into effect to ban surprise billing in private insurance for most emergency care and many instances of nonemergency care, according to the U.S. Department of Health and Human Services (HHS).

Employer-sponsored health insurance premiums increased by 4% for families in 2021, bringing the average annual cost to $22,221 per family, according to the results of a benchmark Kaiser Family Foundation (KFF) Employer Health Benefits survey released in November 2021. KFF also assessed the COVID-19 pandemic’s impact on workplace health benefits, including telemedicine and mental health services.

Few political and policy issues resonate with all Americans as much as the costs of prescription medications, particularly those for acute and chronic diseases that affect the body and spirit, like cancer. Seizing the opportunity for real change, in August 2021 President Joe Biden made a major announcement about his administration’s intent to change the dynamic on the financial impact of drugs and government oversight.

On September 9, 2021, U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra released the Drug Pricing Plan to combat excessive pricing or prescription drugs and reduce the prices paid by the federal government for such drugs, and to address price gouging in the industry. The plan is a part of an initiative from President Biden’s executive order on Promoting Competition in the American Economy to advance the federal government’s ability to address overconcentration, monopolization, and unfair competition in the economy.

U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra celebrated the Children’s Health Insurance Program’s (CHIP’s) 24th anniversary on August 4, 2021, a program that “for more than two decades, has been a lifeline for millions of children and families across America,” with an incredible announcement: in 2020 and 2021, CHIP provided more than 6.8 million enrolled individuals with coverage during the COVID-19 coronavirus pandemic.

When President Biden signed the American Rescue Plan Act of 2021 into law in March 2021, the administration began working to make improvements in areas such as access and affordability by increasing eligibility for financial assistance. The new law lowered premiums for most people who currently had a Marketplace health plan and expanded access to financial assistance for more consumers, and data published in July 2021 showed that from February 15–June 30, 2021, more than 1.5 million Americans signed up for new health insurance coverage using the 2021 Marketplace Special Enrollment Period (SEP).

To achieve value-based, person-centered care, the U.S. healthcare system must promote sustainability and readiness to prepare for future public health emergencies such as the COVID-19 coronavirus pandemic, the Centers for Medicare and Medicaid Service (CMS) said. In August 2021, CMS announced that the Hospital Inpatient Prospective Payment System and Long Term Care Hospital Prospective Payment System final rule will take effect on October 1, 2021, in support of that work.

In July 2021, the Biden-Harris administration, through the U.S. Departments of Health and Human Services (HHS), Labor, and Treasury and the Office of Personnel Management, issued the Requirements Related to Surprise Billing interim final rule to restrict surprise billing. The rule applies to billing for patients in job-based and individual health plans who obtain emergency care, nonemergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.

Approximately 31 million Americans now have healthcare coverage through the Affordable Care Act (ACA), according to a June 2021 issue brief from the office of the assistant secretary for planning and evaluation (ASPE). Of those, 11.3 million consumers were enrolled in Marketplace plans, 14.8 million people were newly enrolled in Medicaid, 1 million individuals were enrolled in ACA’s Basic Health Program option, and nearly 4 million previously eligible adults gained coverage under the Medicaid expansion due to enhanced outreach and increased federal funding. Additionally, insurance rates have fallen across the country since the law’s implementation 11 years ago.

The American Cancer Society, along with 14 other healthcare groups advocating for increased access to care, filed an amicus curiae—Latin for “friend of the court”—urging the U.S. Supreme Court to deny state imposition of engagement requirements, like monthly community service, for Medicaid beneficiaries. The U.S. Supreme Court is likely to spend spring deliberating and convey a judgment before the end of summer.

The rate of uninsured young adults (aged 19–25) fell by more than one third between 2009 and the first quarter of 2014 following the Affordable Care Act’s (ACA’s) Medicaid expansion, according to a February 2021 report from the Urban Institute. With the expansion, young adults also reported improved overall health, increased access to care, and fewer high out-of-pocket costs. 

More than 800 million COVID-19 coronavirus vaccine doses have been administered worldwide. However, 54% of those have been in high-income countries, which contain only 19% of the world’s population, whereas lower-middle income countries have only 33% of the vaccines for their 81% of the population. Those disparities have serious implications and limit equal access to health care, including vaccinations. The World Health Organization (WHO) is campaigning to address vaccine inequity on a global scale. 

The Biden administration’s American Rescue Plan (APR) is the largest, single piece of legislation focused on economics since Franklin D. Roosevelt proposed in his New Deal programs to pull the United States out of the Great Depression. Sweeping in scope, two of APR’s goals are to make health care accessible for all and to create formal plans for addressing racial disparities. 

From Teddy Roosevelt to JFK, presidents throughout history have sent legislation to Capitol Hill with the intent to expand healthcare coverage to more Americans. Finally, when Lyndon B. Johnson drafted a bill and pushed it through Congress by expanding sections of the Social Security Act, Medicare become an entitlement and is now implemented by the Centers for Medicare and Medicaid Services (CMS). During the past 50 years, federal health coverage has grown to include Medicaid, maternal and childcare assistance, public health programs, and prescription medication pricing.

Drug pricing is a bipartisan issue that ranks very high on public opinion polling, and patients with cancer in particular feel the effects of an unregulated market. 

Understanding correct coding strategies is an important skill that affects billing and reimbursement for value-based cancer care. Meeting the requirements for complete and accurate documentation is critical to support healthcare claims. Both nurses and advanced practice providers have responsibilities in this work.