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Impact of the healthcare payment system on patient access to oral anticancer drugs: an illustration from the French and United States contexts

Laure Benjamin123*, Valérie Buthion4, Gwenaëlle Vidal-Trécan1256 and Pascal Briot7

Author Affiliations

1 Department of Epidemiology, Evaluation and Health Policies, University of Paris Descartes, Paris Sorbonne Cité, Paris, France

2 School of Public Health (EHESP), Rennes, France

3 Health Economics and Outcomes Research, GlaxoSmithKline, 100 route de Versailles, Marly le Roi, Cedex 78163, France

4 COACTIS EA 4161, University of Lyon, 14 avenue Berthelot, Lyon 69363, Cedex 07, France

5 Department of Public Health, Quality and Safety of care, Paris Center University Hospitals, AP-HP, 27 rue du Faubourg Saint Jacques, Paris 75014, France

6 Department of Public Health, Faculty of Medicine, Paris Descartes University, Paris Sorbonne Cité, Paris, France

7 Institute for Health Care Delivery Research, Intermountain Healthcare, 36 South State Street, 16th Floor, Salt Lake City, UT 84111, USA

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BMC Health Services Research 2014, 14:274  doi:10.1186/1472-6963-14-274

Published: 20 June 2014



Oral anticancer drugs (OADs) allow treating a growing range of cancers. Despite their convenience, their acceptance by healthcare professionals and patients may be affected by medical, economical and organizational factors. The way the healthcare payment system (HPS) reimburses OADs or finances hospital activities may impact patients’ access to such drugs. We discuss how the HPS in France and USA may generate disincentives to the use of OADs in certain circumstances.


French public and private hospitals are financed by National Health Insurance (NHI) according to the nature and volume of medical services provided annually. Patients receiving intravenous anticancer drugs (IADs) in a hospital setting generate services, while those receiving OADs shift a part of service provision from the hospital to the community. In 2013, two million outpatient IADs sessions were performed, representing a cost of €815 million to the NHI, but positive contribution margin of €86 million to hospitals. Substitution of IADs by OADs mechanically induces a shortfall in hospital income related to hospitalizations. Such economic constraints may partially contribute to making physicians reluctant to prescribe OADs. In the US healthcare system, coverage for OADs is less favorable than coverage for injectable anticancer drugs. In 2006, a Cancer Drug Coverage Parity Act was adopted by several states in order to provide patients with better coverage for OADs. Nonetheless, the complexity of reimbursement systems and multiple reimbursement channels from private insurance represent real economic barriers which may prevent patients with low income being treated with OADs. From an organizational perspective, in both countries the use of OADs generates additional activities related to physician consultations, therapeutic education and healthcare coordination between hospitals and community settings, which are not considered in the funding of hospitals activities so far.


Funding of healthcare services is a critical factor influencing in part the choice of cancer treatments and this is expected to become increasingly important as economic constraints grow. Drug reimbursement systems and hospital financing changes, coupled with other accompanying measures, should contribute to improve equal and safe patient access to appropriate anticancer drugs and improve the management and care pathway of cancer patients.

Oral; Chemotherapy; Targeted therapy; Healthcare payment system; Reimbursement; Hospital funding; Medicare Part D; Cancer