When Payers, Not Oncologists, Dictate the Use of Antiemetics

Antiemetics, or anti-nausea drugs, are one of the most valuable contributions to cancer care. I remember when I began to work in Cancer World that nausea and vomiting inevitably accompanied chemotherapy and were often terrible. We handed out plastic basins to patients as they left the infusion area and many didn’t even make it to their cars before being sick. There were countless stories of nights spent on the bathroom floor and misery that persisted for days. All new patients came for their first treatment anticipating the worst, and all too often, they were right.

The overarching loss of control and decision-making autonomy affects us all.

As you know, there are now multiple effective—and very expensive—drugs to control and even prevent nausea and vomiting. Many, if not most, people get through chemotherapy without once vomiting. Sure, there may be some stomach unrest and food aversions, but it is nothing like the old days. Another important point is that intractable nausea and vomiting used to limit the doses and duration of chemotherapy; there were side effects that no one could be expected to endure.

Unfortunately, some insurance companies/payers are now limiting the quantity of antiemetics that will be covered. This is part of the larger problem of skyrocketing drug costs, but this is one that really matters to virtually all oncology patients and providers. Payers have several strategies to limit their costs on drugs: prior authorizations, step therapy (encouraging patients to use less expensive alternatives), and quantity limits. They may use these alternatives if they think a particular treatment/drug is unnecessary and a cheaper one could be used instead. They might also agree to cover X number of treatments with a particular drug but not X plus one.

The basic question here, of course, is how did we get to this moment that payers rather than doctors are making the decisions of how to treat a cancer patient? The same question applies in other areas of medical care, but, since cancer drugs are so expensive, it comes up more often in oncology. These limitations and denials can result in limiting patients’ access to quality care and more emotional and physical suffering than is necessary. Sometimes cancer treatments are interrupted or even stopped while these financial issues are addressed.

The impact is also profound on doctors and health care systems. The overarching loss of control and decision-making autonomy affects us all. Clinicians are forced to spend time on administrative tasks, negotiating with insurance companies, filling out forms, waiting on hold to argue a case. In attempts to relieve physicians of these tasks, other clinicians (usually nurses or nurse practitioners) often take them on. Additional staff may need to be hired and levels of responsibility assigned per their skill sets. All of this is expensive. To counter limits on quantities, some clinicians encourage their patients to use drug discount websites or even prescribe some medications at higher doses and then instruct the patient to take fewer or to halve the pills.

The encouraging news is that attention is being paid to this issue, and there are increasingly assertive efforts by clinicians, professional groups, and health care systems to end these restrictions.