Variation in Use of Lung Cancer Targeted Therapies Across State Medicaid Programs, 2020-2021

Key Points Question Does the use of targeted therapies for non-small cell lung cancer (NSCLC) vary across state Medicaid programs? Findings This cross-sectional study found substantial variation in the use of targeted therapies for EGFR- and ALK-altered NSCLC across Medicaid programs, with evidence of underuse in 30 of 33 states. The observed variation was associated with Medicaid policies, oncologist density, and state gross domestic product per capita. Meaning This study suggests that targeted therapies are underused in many state Medicaid programs, limiting access to efficacious treatments; attention is needed for state policies and characteristics that may limit access to these useful drugs. Importance Targeted therapies for EGFR (OMIM 131550)- and ALK (OMIM 105590)-altered metastatic non-small cell lung cancer (NSCLC) substantially improve outcomes for some patients. However, use of these therapies is lower among Medicaid patients, and access to oncology care varies across state Medicaid programs. Evidence is lacking on how use of targeted therapies for metastatic NSCLC varies across state Medicaid programs. Objectives To characterize state-level variation in the use of targeted therapies among Medicaid patients with metastatic NSCLC and to describe factors associated with this variation. Design, Setting, and Participants This cross-sectional study used publicly available data from the Medicaid Drug Utilization Database from 2020 and 2021 and peer-reviewed data on NSCLC incidence, the prevalence of EGFR and ALK alterations, and expected treatment durations to estimate expected use of targeted therapies for EGFR- and ALK-altered NSCLC in 33 states. Exposures State-specific Medicaid programs and state policies and characteristics. Main Outcomes and Measures The primary outcome was the estimated proportion of person-time of Medicaid patients with EGFR- or ALK-altered NSCLC associated with receipt of targeted therapy in each state Medicaid program. Nested linear regression models examined associations between the observed variation and state policies and characteristics. Results There were an estimated 3461 person-years in which EGFR- and ALK-targeted therapies were indicated in 2020 and 2021. During these years, only 2281 person-years of EGFR- and ALK-targeted therapies were dispensed to Medicaid patients, suggesting that an estimated 66% of Medicaid patients with EGFR- and ALK-altered metastatic disease received indicated targeted therapies across all states. Rates of targeted therapy use ranged from 18% in Arkansas to 113% in Massachusetts; 30 of 33 states (91%) had lower rates of targeted therapy use than expected. The observed variation across state Medicaid programs was associated with Medicaid policies, the density of oncologists, and state gross domestic product per capita. Conclusions and Relevance This study suggests that rates of targeted therapy use among Medicaid patients with EGFR- and ALK-altered NSCLC were lower than expected and varied across state Medicaid programs. State policies and characteristics were associated with the observed variation, indicating where interventions could improve access to treatment and outcomes for patients with NSCLC. This cross-sectional study characterizes state-level variation in the use of targeted therapies among Medicaid patients with metastatic non-small cell lung cancer and describes factors associated with this variation.