Страховое покрытие стало главным препятствием для пациентов с раком груди, выбирающих домашние инъекции под наблюдением телемедицины

Satisfaction rates with a telemedicine-guided hormone self-injection protocol were high among patients with breast cancer who received health insurance reimbursement according to new research. Overall, insurance coverage, which was variable and unpredictable, was the main obstacle to patient’s receiving at-home injections following enrollment in the small feasibility study. Well over half of those who completed three injections “opted to continue home administration beyond the study end,” reported a team of investigators at the Memorial Sloan Kettering Cancer Center (MSKCC) in New York City in JAMA Network Open. Partly due to the introduction of subcutaneous prefilled syringes, an increasing number of cancer drugs are approved for self-injection. These include agents such as denosumab to treat the bone-related complications of cancer and granulocyte colony-stimulating factors like filgrastim that boost white blood cell counts depleted by chemotherapy. MSKCC is among cancer centers that provide a website instructing patients on how to self-inject these types of drugs. However, insurance companies typically distinguish between injections administered in a clinic by a medical professional and those administered at home by the patient. Using Medicare as an example, injections given during an office visit are a medical benefit and included in standard Medicare coverage. However, home injections are a pharmacy benefit covered by Part D supplemental policies that are selected independent of part B standard Medicare and vary wildly. Patients with a comprehensive Part D plan will get reimbursed. Those with cheaper plans will not. In this study, one insurance company asked for a copay of $2000 per self-injection, which is not just a disincentive but would serve as a de facto denial of service to most patients. Injectable gonadotropin-releasing hormone agonists (GnRHa) are commonly used for breast cancer and prostate cancer. Although some cancer centers do permit and instruct patients on self-injection, Erin M. Bange, MD, MSCE, the corresponding author of the new feasibility study, reported that this is not standard of care and not well studied. Bange, who is an oncologist specializing in genitourinary cancers at MSKCC, said the goal of her research was to test patient acceptance and satisfaction. Methods and Results In the feasibility protocol, premenopausal women with breast cancer on an injectable GnRHa were invited to receive in-clinic training on self-injection followed by optional telemedicine supervision of further home injections. Of the 105 eligible patients to participate in this study, 54 agreed to participate. The majority of those who declined did so from lack of interest. Of those 54 patients, 30 (56%) received insurance authorization, but 18 were required to make a copayment. These averaged $61 but the range was broad, and six patients subsequently dropped out. The median copayment following the dropouts was $38. Of the 24 participants who entered the self-injection protocol, only one left as a result of challenges related to treatment. The others completed at least one injection. Nineteen of 24 (79%) completed two injections, and the remainder — or 75% of those who entered the protocol — completed all injections and opted to continue with self-administration when the study ended at 6 months. Although telemedicine visits were available to all patients after the in-clinic training, just 13 (54%) opted to employ this option for any subsequent home injection. Insurance coverage for medication was the “primary barrier” for self-administering injections in the feasibility study once enrolled, the authors reported. Among those who participated during the entirety of the study, time savings (88%), control over scheduling (80%), and overall convenience (77%) were cited as key benefits from the home-injection program. Approvals were quick with little or low copays in some, but others were issued, if issued at all, only after letters of appeal and peer-to-peer discussions to seek approval. Five patients withdrew after tiring of a long insurance approval process. New 10,000-Patient Study The authors are now testing this process in a larger pragmatic trial enrolling more than 10,000 patients with breast and prostate cancer across MSK,” Bange told Medscape Medical News. “Based on what we learned from the pilot, we developed several strategies to reduce the administrative burden on both patients and clinicians,” she said. These included: - developing templates for letters of medical necessity that can be easily adapted by clinical teams; - establishing a dedicated pharmacy team to assist with medication processing and dispensing; and - conducting extensive educational initiatives with nursing, pharmacy, and clinical teams to provide guidance on the program and best practices. A streamlined communication channel to outpatient financial services has also been created for the new initiative. “Since implementing these additional resources, we have seen insurance approval rates increase substantially,” Bange said. The high rate of patient satisfaction among those who completed the study is providing the basis “to build the infrastructure needed to make this option made available more broadly across oncology and to better understand the potential benefits for patients, clinicians, and healthcare systems.” In the feasibility study, the majority of the patients lived within 25 miles of the clinic, but the median door-to-door visit time was 2 hours. There was a substantial savings in travel times for the five patients who lived more than 50 miles away, but respondents to post-study survey reported time savings were meaningful even when distances to the clinic were modest. The results of the feasibility study are not surprising, Mitchell von Itzstein, MD, who was not involved in the study, told Medscape Medical News. Given the convenience of telemedicine to guide home treatment, “I do not think is necessary to do extensive trials in these areas to measure things like cost effectiveness before offering these options to patients,” continued von Itzstein, who led a 2024 study on applying telemedicine to cancer research and is an assistant professor in the Division of Hematology and Oncology at the University of Texas Southwestern Medical Center in Dallas. While acknowledging that telemedicine will never replace in-person visits,” von Itzstein said, “there are many situations…that make telemedicine a great option for patients, particularly for follow-up visits.” Bange and von Itzstein reported no potential conflicts of interest. Ted Bosworth, a career medical writer based in New York City, has been covering advances in clinical medicine, including oncology, for several decades.