New Pills Gain In Cancer Fight, Till Cost Gets In Way

Feb. 26--For a decade, Jim Holt had beaten back multiple myeloma using every weapon in the arsenal:

Surgery to remove a baseball-size tumor from his head. A stem cell transplant at Duke University. Chemotherapy, multiple times.

When lab work showed the blood cancer's levels creeping up again in 2008, his doctor suggested a new oral chemotherapy drug called Revlimid.

The cost was a jaw-dropper: $8,000 a month.

"I thought, 'What? Are they trying to rob us?' " said Holt, 57, who lives in Virginia Beach.

Even with health insurance, his co-pay for the drug was going to be $800 a month.

Instead, he went with what his doctor said would be a good, but probably less effective, intravenous chemo option. He drove from Virginia Beach to Suffolk several times a week for more than two years to sit for a couple of hours with an IV needle in his arm.

Because the IV procedure was performed in a doctor's office, his insurance covered almost the entire cost.

It's a dilemma that cancer patients across the country face as newer, and more expensive, oral medications come onto the market. Insurance plans cover IV chemotherapy as a medical benefit but consider oral med chemotherapy part of a patient's drug plan, which usually requires a higher co-pay.

So the more convenient, less invasive method often gets trumped because of cost.

In Virginia, the General Assembly is considering legislation that would require health plans' coverage of oral chemo meds to be more in line with coverage of IV chemo. Fifteen states and the District of Columbia have passed similar "parity" laws. Such a bill is also before Congress.

In Virginia, a Senate version has passed both chambers, and a House version goes before a Senate committee on Monday.

Doug Gray, executive director of the Virginia Association of Health Plans, said patients have a legitimate concern, but the challenge is finding a solution that works for everyone. What people often don't consider in parity bills, he said, is that when costs become more affordable for one type of drug, that makes another type less affordable, or costs are increased in areas such as premiums. The vast majority of prescription drugs fall into affordable tiers, and it's the newer drugs just out on the market that are so expensive, Gray said.

"Do you want the 98 percent to help the 2 percent get more affordable meds?" he asked.

Becky Lawson, spokeswoman for Optima Health, said the insurance provider is evaluating the impact of the bill.

But Dr. Scott Kruger, an oncologist at Virginia Oncology Associates in Norfolk, said the current reimbursement system is outdated. In many situations the oral meds are more effective, and many patients are forced to choose a less effective IV option solely because it's cheaper.

Kruger said that particularly during the past five years, research has led to oral meds that stem cancer growth. They're turning cancers into chronic diseases that can be managed for years through medication.

If more patients could afford the oral meds, Kruger said, it would reduce hospital costs as well as the amount of time patients lose from work. He said each of the group's 12 practices has one employee whose sole job is to link patients who can't afford their oral meds with organizations that can help them.

Virginia's bill, if passed and signed by the governor, would provide more coverage for oral meds through private insurance plans and state health insurance. Some states have passed stronger legislation that require the coverage to be equal, while Virginia's bill would simply bring coverage of oral meds more in line with that of IV chemo.

Parity bills are important to people with multiple myeloma because they often use several methods to combat it, according to Meghan Buzby, who works for the International Myeloma Foundation.

In some cases, IV chemo will work for a while but then stops being effective. At that point, an oral medication is usually critical in fighting the cancer.

"When one method stops working, they need to go back into the toolbox," Buzby said.

In Holt's case, the IV chemo worked for 2-1/2 years, but then his cancer levels began rising again. Last March, his doctor strongly recommended Revlimid.

Holt didn't have any good options, so his wife, Faye Holt, got on her computer and investigated programs that could help them pay the bills. She found a patient assistance program, through the company that makes the drug, that is helping them with co-pays. The medication is keeping Jim's cancer at bay while he awaits a clinical drug trial at Duke University.

"Every relapse you think, 'Oh my God, I'm going to be a widow,' " Faye said. "And then another treatment comes along."

Jim Holt, who is on disability after working for years as a manager at Newport News Shipbuilding, said not everyone is as lucky as he has been in finding help.

"People die because they can't afford it," he said.

He is thankful for the various treatments, as he's now a 13-year survivor, the longest in his support group. That's given him time to enjoy his two grandchildren and to cheer on his favorite team, the New York Giants.

He holds up the bottle of white capsules and says, "That's gold. I should sell it on the black market."

Cindy Jones, 53, also knows the experience of fighting cancer and prescription drug costs at the same time. The Virginia Beach woman is battling her third type of cancer. First she fought off ovarian cancer in 1999 with IV chemotherapy for three months. Then in 2005, she was diagnosed with breast cancer. Another three months of IV chemo put her in remission.

In 2006, she was diagnosed with colon cancer. She had IV chemo for six months, but it didn't work, so she tried another type of IV chemo drug for eight more weeks.

After that failed in 2007, her doctor recommended Xeloda, an oral med that costs $2,000 a month. Medicare, which she qualified for because of her illness, paid 80 percent, but she still needed $464 a month for her co-pay. For a while, she was insured through COBRA, the Consolidated Omnibus Budget Reconciliation Act, but then that ran out.

"I freaked out. The bills were starting to pile up," said Jones, who lives with her parents now because of her illness and finances. She looked into getting other supplemental insurance but the cost would have swallowed her entire disability check.

Her doctor's office wrote off most of its bill so she could afford the medication. In 2010, she discovered the Patient Advocate Foundation, a Hampton-based group that helps with co-pays through grants and by connecting her with other charity programs.

The foundation has been lobbying for passage of parity bills for chemo meds. Larry Lanier, its vice president of government affairs, said that the group helped 287,000 people across the country in 2010 pay for $31 million in drugs. In Virginia, it has helped more than 6,000 patients.

He said studies have shown that states that passed the parity legislation have not seen increases in premiums.

Jones has testified in Richmond and before Congress for parity bills.

"With the IV drugs, you have more anemia and hair loss. You are sitting for hours in a chair, hooked up with an IV," said Jones, who said the veins in one of her arms can't even be used anymore. "With the oral meds, I'm able to take those at home. It's less time-consuming and less invasive."

Elizabeth Simpson, 757-446-2635, [email protected]

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