My View: Legislature should give patients access to best cancer therapies

By Richard Frame

For the Deseret News

Published: Tuesday, Feb. 19 2013 9:50 a.m. MST

Kellie Gubler and her husband Dave listen during a SB189 hearing in the Senate Building. Speakers address the Senate Business and Labor Committee Tuesday, Feb. 19, 2013 hearing arguments on SB189.

Scott G Winterton, Deseret News

Whenever I give a new patient a cancer diagnosis, I always want to assure them they’ll receive the best treatment possible. When your life is on the line, you don’t want to be thinking about whether or not you’ll be able to afford the medicine that will give you the best chance of survival.

But in reality, my treatment options are often limited by economics, even when a patient has “good” insurance. Outdated insurance co-pay policies often mean patients cannot afford the best medication to treat their particular type of cancer.

If chemotherapy is given in pill form, patients are often required to pay a very high co-pay out of their own pocket. The pharmaceutical benefit of their insurance policy determines the amount. However, many insurance plans will only require a normal doctor’s visit co-pay (often less than $100), if treatment is provided in intravenous (IV) form.

Recently, there have been tremendous advances in fighting cancer. One is the significant improvement in oral chemotherapy now available for many cancers. Cancer fighting pills have tremendous advantages. One does not need spend hours in a chemo chair and there is no IV access necessary. Nevertheless, oral chemotherapy has new, different and sometimes severe toxicities that need to be monitored closely.

Unfortunately, payment policies for cancer treatments have not kept up with advances in drug development. Two recent examples of real patients where I practice illustrate the problem. In both cases, the oncologist determined the best medication to treat the specific kind of cancer was an oral therapy, meaning the patient could take pills in the comfort of their home.

The monthly cost of one patient’s oral therapy, which would have been billed to insurance, was $7,719. The patient’s co-pay would have been $2,856. The patient couldn’t afford this amount, especially since he/she likely needed multiple courses of the treatment. So, the patient was given the option of an IV treatment, for which the insurance company will be billed $15,575. The patient will pay nothing since the insurance plan requires no co-pay from the patient for the injectable treatment.

The monthly cost of the second patient’s oral therapy would have been $5,954, with the patient co-pay being $2,397. Again, this was too much for the patient, so an IV therapy was considered, for which the insurance company will be billed $5,614. The patient co-pay will be $842 applicable to the patient’s annual deductible, or $0 if their deductible has been met.

As you can see, in both of these cases, the patient was given a treatment deemed inferior by the doctor because of the pharmaceutical co-pay disparity. In the first case, the insurance company would have actually saved $7,856 by allowing the oral therapy in place of the IV. In the second case, the insurance company would have only paid $340 more for the oral therapy recommended by the doctor.

I commend Sen. Curtis Bramble, R-Provo, for sponsoring SB 189, which would end this disparity. The bill does not mandate that insurers cover oral chemotherapy. It simply says that insurers that do elect to cover cancer treatments should treat oral and IV therapies the same. Twenty-one states and the District of Columbia have already passed similar legislation. None of the states have seen any significant increases to insurance premiums.

Patients should not be punished financially if the treatment for their cancer is best accomplished with pills instead of IV drugs. More and more cancers will be treated with pills in the future. For the benefit of our friends and family with cancer, it’s time we end the arbitrary disparity between IV and pill chemotherapies, before the problem gets worse.

Dr. Richard Frame is a practicing Oncologist at Utah Cancer Specialists. He also serves as Chair of the Community Oncology Alliance Patient Advocacy Network.

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