New Cancer Cures Insurers Won’t Cover

Advances in cancer treatment are saving lives and cutting health-care costs. But because many health-insurance plans haven't caught up with the times, nearly half of all cancer patients are forced to choose between the treatment that could save their lives - or one that's paid for.

John Rykert had been battling advanced basal-cell carcinoma for two decades by cutting out the tumors as they appeared. In 2009, after 20 surgeries lasting 10 hours each, Rykert' s doctor said that the cancer had spread so far that the only option left would be to carve out half his face. But then Rykert was given Erivedge, then an experimental drug, which shut down the genetic mutation causing his skin cancer to spread.

Erivedge shrank Rykert's tumors almost immediately and shut down the skin cancer. He suffered some hair loss and muscle cramps, but four years later he is alive.

Such stories are increasingly common. As scientists find the shut-off switch for specific cancer-causing genes, they can make pills that go after cancer cells and block the specific biological mechanisms that produce them.

These pills are not only less toxic than conventional IV chemotherapy, they've turned once-incurable cancers such a myeloma, breast cancer and even pancreatic cancer into manageable diseases.

But insurance coverage hasn't kept up with medical innovation. Instead, most insurers follow Medicare's 40-year-old approach - which covers IV treatments generously, capping out-of-pocket costs at about $3,000, but charges the patient up to 50 percent for oral cancer drugs, even when they're the only treatment that will work.

And targeted cancer pills such as Gleevec, Tykerb (for breast cancer) and Revlimid can cost tens of thousands of dollars a year. Ironically, that's not much more expensive than many IV cancer treatments; the coverage cap isn't even about saving money.

Hence, when Robert Adler's multiple myeloma returned after his IV chemotherapy, his doctor recommended the pill Revlimid. While his insurer had paid all but a few hundred dollars of his previous treatment, it saddled him with out-of-pocket costs of $42,000 because Revlimid counts as a pharmacy benefit.

Again, nearly half of all cancer patients are in plans that force them to choose between a treatment that's paid for and one that could save their lives.

Sadly, several studies show, 25 percent of patients don't even fill their initial prescriptions for cancer pills when the co-pays exceed $500. Even more will stop or interrupt treatment.

Neither Medicare or private health insurers are closing the gap between coverage and innovation. Instead, a survey of plans conducted by the Zitter Group found that insurers "recognize that oral therapy cost-sharing requirements actively encourage patients to use infusible products."

This is akin to paying for an iron lung machine but not a polio vaccine.

To address this innovation gap, Rep. Brian Higgins (DBuffalo) has introduced the Cancer Drug Coverage Parity Act, which would require health plans to equalize co-pays for all forms of cancer care.

Again, these pills have meant huge progress in the war against cancer. Since targeted cancer therapies were introduced in 1993, the number of cancer survivors has more than doubled from about 6.8 million to 14 million today. That translates into 43 million added years of life - which Columbia University economist Frank Lichtenberg says added $4.2 trillion to our economy.

These new treatments are also saving money by reducing the need for hospitalization. If the number of cancer patients hospitalized had remained constant since 1993, we'd have spent $1.3 trillion more on cancer care. Meanwhile, the amount we spend on cancer medications (old and new) has remained 5 percent of total US health-care spending.

Being able to decode our genome to treat cancer is just the start of a total transformation of medicine - but most health-care "reforms" impede such progress. The Cancer Parity Act aligns how we pay for health care with the future of medicine.

Robert Goldberg is vice president of the Center for Medicine in the Public Interest.