Every day in Massachusetts, 105 people get diagnosed with cancer, beginning a long, scary and sometimes unpleasant process of treatment. For increasing numbers of cancer patients, it also creates a crushing financial burden for them and their families at a time in their lives when they have enough to worry about.
How is this possible in a state with nearly universal health insurance coverage? The answer lies in the combination of innovation and outdated insurance practices.
Cancer treatment is changing. Increasingly, pills are replacing intravenous chemotherapy administered in a clinical setting. Since 2010, eight of the 11 oncology drugs approved by the Federal Drug Administration are oral treatments.
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But insurance companies have been slow to adapt to this change. Insurers treat intravenous chemotherapy as a medical visit, with a modest co-payment and a capped annual out-of-pocket cost, but they treat oral chemotherapy as a drug benefit, for which patients pay a percentage of a prescription’s cost, up to 50 percent, and have no annual limit. Chemotherapy agents, whether in oral or intravenous form, are expensive, so those taking a pill face out-of-pocket costs in the thousands and even tens of thousands of dollars every year.
State Senator Stephen M. Brewer of Barre, the chairman of the Senate Ways and Means Committee, has filed legislation to eliminate this disparity in coverage.
The bill does not create a new coverage mandate; it simply tells insurers that they cannot require higher patient costs for oral chemotherapy. Nor will the legislation lead to higher health care costs. In fact, the use of oral anti-cancer medications usually results in fewer hospital visits, which means fewer staff and administrative costs and fewer risks of infection, illness and complications — reducing the overall cost of health care. The legislation is also consistent with current efforts underway in the Legislature to move medical care away from treatment in expensive hospital settings. BlueCross BlueShield told the Maryland General Assembly, which passed similar legislation earlier this year, that the measure would cause “no significant fiscal impacts.” In the 20 states where this legislation has been enacted, there is no evidence that the law has caused an increase in health insurance premiums.
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To be sure, oral chemotherapy provides a measure of convenience and comfort to cancer patients during a difficult and painful time in their lives. But there are even more important medical reasons for not penalizing patients financially for taking a pill. In contrast to intravenous therapy, which often kills healthy cells along with cancerous ones, many of the new oral oncology drugs target specific biological processes in cancer cells and block their growth. Some cancer drugs are only available in pill form. For example, the drug imatinib, which treats chronic myelogenous leukemia, comes only in pill form, as does an even newer drug, lenalidomide, which treats multiple myeloma and myelodyplastic syndrome.
At its root, insurance is supposed to protect people from financial ruin if they encounter catastrophic illness or injury. In Massachusetts, that is not happening for some cancer patients. In a state that, rightly, prides itself on providing access to health care to all, this problem represents a major flaw in the system — one the Legislature should act quickly to fix.
Dr. Robert J. Soiffer is chief of hematolgic malignancies at Dana-Farber Cancer Institute. Justin Smith is a cancer survivor and vice president of the Leukemia and Lymphoma Society Massachusetts Chapter.
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