Merit-based Claim Adjudication for Cancer Treatment Toxicities – Policy Trends that Lower Downstream Costs

Background.—Due largely to the lack of effective therapeutic options, between 1973-2013, chemoradiation toxic mucositis (CRTM) has remained an uncapped expenditure for 40 years, with incremental costs of $17,000-$40,000 per patient per episode. Costs in patient morbidity and mortality have continued as well. A recent therapeutic option associated with complete prevention and/or rapid sustained elimination (high potency polymerized cross-linked sucralfate, HPPCLS) delivers value by eliminating downstream costs CRTM experienced in the first 12 months. While many insurers carry the therapy as a specialty pharmacy support drug, few are familiar with the associated health economic benefits and the statutory requirements driving its coverage. Purpose.—To present the rationale behind early policy trends that frame CRTM as an emergent/urgent medical condition mandated coverage as an essential health benefit. Rather than problematic for costs, this coverage trend appears to be value-based. Methods.—Discuss early adverse claim experience of HPPCLS. Present the costs, tenets and statutes driving policy trend toward obligatory coverage of CRTM. Review the ethical (fiduciary) and statutory requirements for CRTM coverage. Results.—CRTM coverage is ethically responsible since it is a direct consequence of authorized cancer treatment. The symptom/signs complex of CRTM meets the ‘prudent layperson’ statutory definition of emergency medical condition. All previously uncapped downstream costs of CRTM can be reduced to the cost of therapy, saving $15-$30K per patient per CRTM episode. Conclusions.—Policy trend of CRTM coverage as an emergent/urgent medical condition is a value-based approach of toxicity management, conserving resources, cutting costs and eliminating patient morbidity and mortality.