Out-of-pocket cost modeling of adjuvant antiestrogen and radiation therapy after lumpectomy for early-stage breast cancer across Medicaid and Medicare plans.

PURPOSE: The optimal adjuvant therapy (anti-estrogen therapy (ET) + radiotherapy or ET alone, or in some reports radiotherapy alone) in older women with early-stage breast cancer has been highly debated. However, granular details on the role of insurance in the out-of-pocket cost for patients receiving ET with or without radiotherapy are lacking. This project disaggregates out-of-pocket costs by insurance plans to increase treatment cost transparency.

METHODS AND MATERIALS: Several radiotherapy schedules are accepted standards as per the National Comprehensive Cancer Network guidelines. For our financial estimate model, we utilized the five-fraction and fifteen-fraction radiotherapy, and ET prescribed over a five-year duration. The total aggregate out-of-pocket costs were determined from the sum of treatment costs, deductibles, and copays/coinsurance based on Medicaid, Original Medicare, Medigap Plan G, and Medicare Part D Rx plans. The model assumes a Medicare- and/or Medicaid-eligible patient ≥ 70 years of age with node-negative, early-stage estrogen-receptor-positive breast cancer. Patient out-of-pocket costs were estimated from publicly available insurance data from plan-specific benefit coverage materials using a five-year time horizon.

RESULTS: Original Medicare beneficiaries face a total out-of-pocket treatment charge of $2,738.52 for ET alone, $2,221.26 for five-fraction radiotherapy alone, $2,573.92 for fifteen-fraction radiotherapy alone, $3,361.26 for combined ET+ five-fraction radiotherapy, and $3,713.92 for combined ET + fifteen-fraction radiotherapy. Medigap Plan G beneficiaries have an out-of-pocket charge of $1,130.00 with radiotherapy alone and face an out-of-pocket of $2,270.00 for ET alone and combined ET+radiotherapy. For Medicaid beneficiaries - all treatments approved by Medicaid - are covered without limit, resulting in no out-of-pocket expense for either adjuvant treatment option.

CONCLUSIONS: This model (based on actual cost estimates per insurance plan rather than claims data) by estimating expenses within Medicare and Medicaid plans provides a level of transparency to patient cost. With knowledge of the costs borne by patients themselves, treatment decisions informed by patients' individual priorities and preferences may be further enhanced.