As Pills Treat Cancer, Insurance Lags Behind
The New York Times
Published: April 14, 2009
Brian Lee for The New York Times
Chuck Stauffer’s insurance covered hardly any of the cost of the cancer pills the doctor prescribed for him to take at home.
Chuck Stauffer’s insurance covered the surgery to remove his brain tumor. It covered his brain scans. And it would have paid fully for tens of thousands of dollars of intravenous chemotherapy at a doctor’s office or hospital.
“Because it was a pill,” he said, “I had to pay — not the insurance.”
Pills and capsules are the new wave in cancer treatment, expected to account for 25 percent of all cancer medicines in a few years, up from less than 10 percent now.
The oral drugs can free patients from frequent trips to a clinic to be hooked to an intravenous line for hours. Fewer visits might save the health system money as well as time. And the pills are a step toward making cancer a manageable chronic condition, like diabetes.
But for many patients, exchanging an I.V. bag for a pill is a lopsided trade because the economics and practice of cancer medicine have not caught up with the convenience of oral drugs.
Start with the double ledger of drug insurance. Drugs that are infused at a clinic are typically paid for as a medical benefit, like surgery. Pills, though, are usually covered by prescription drug plans, which are typically much less generous; for expensive cancer pills, patients might face huge co-payments or quickly exceed an annual coverage limit. Sometimes, as in Mr. Stauffer’s case, a single insurer is involved.
Many times, though, a separate company — a so-called pharmacy benefit manager — provides the prescription drug coverage.
The growing use of cancer pills is also thrusting patients and doctors into new roles they have not yet fully mastered. Without a physician’s direct supervision, side effects can be missed. Some patients do not take all their medicine, raising the risk their cancer will worsen. Others take too many pills, risking toxic reactions.
For doctors, the new drugs also pose financial challenges. Physicians can profit from infusing drugs in their offices but not from writing prescriptions that are filled at a pharmacy.
With oral cancer drugs, “the technology has outstripped the ability of society to integrate it into the mainstream in a smooth fashion,” said Carlton Sedberry, a pharmacy expert at Medical Marketing Economics, a consulting firm.
So far the health reform debate in
Infused drugs, of course, can also be frightfully expensive and under some insurance plans — including Medicare — can carry big co-payments. But it is the oral drugs that seem to be causing a disproportionate number of financial problems for cancer patients. The Patient Advocate Foundation, an organization that helps people make insurance co-payments for cancer drugs, says oral medicines accounted for 56 percent of the cases in which it helped Medicare patients last year, even though far more cancer patients were on intravenous drugs.
One oncology practice in central
Although drug makers are developing oral versions of some infused cancer medications, most of the new pills and capsules have no intravenous equivalent.
The oral exemplar is Gleevec from Novartis, which since its approval in 2001 has helped turn chronic myeloid leukemia as well as gastrointestinal stromal tumors into manageable diseases for many patients.
Douglas Jenson, 75, of
Making it even easier, Mr. Jenson gets his Gleevec free because he participated in an early clinical trial of the drug. Otherwise it would cost more than $40,000 a year.
While Mr. Jenson has been diligent about taking his five capsules every day at lunchtime, research indicates that many patients on the oral drugs do not consistently take the proper dose. One study, for example, found that Gleevec patients, on average, were taking only 75 percent of their prescribed doses.
Some cancer patients skip pills or stop taking them completely — whether because of costs, forgetfulness, side effects, complicated regimens or other factors.
“When I first started looking into this, I thought, ‘People with
cancer have too much to lose, how can they not take their
drugs?’ ” said Dr. Ann Partridge, an oncologist at Dana-Farber
Cancer Institute in
Some other cancer patients, meanwhile, end up taking too many pills.
For many patients, though, the main challenge is not taking their pills, but paying for them. Under Medicare, most oral cancer drugs are covered by the Part D prescription drug program, which has a 25 percent co-payment. It also has the annual “doughnut hole” — reached when a patient’s total drug costs hit $2,700, after which the patient must shoulder the next $3,000 or so before coverage resumes.
Mary Francis Thomas of
Drug companies say they provide free drugs for some patients and give money to charities for co-payment assistance. And Lee Newcomer, senior vice president for oncology at UnitedHealthcare, the big insurer, said many commercial policies capped total annual out-of-pocket expenditures, so patients should not have huge co-payments month after month.
But nurses and patient advocates say that many patients still have trouble paying for the drugs.
Mr. Stauffer, the
Mr. Stauffer’s insurer, Regence Blue Cross Blue Shield, even
reimbursed him for the money he had already spent on Temodar.
Several other states, including