State could force insurance coverage of 'biomarker' testing

When Carla Prothro found out she had cancerous growths in both lungs, her doctors thought it had metastasized, or traveled, from somewhere else in her body.

Prothro's treatment would have been based on that wrong assumption if not for subsequent biomarker testing, a procedure that analyzes various biological markers to learn more about a person's disease. After the results came back, she learned that the two cancers had different genetic makeups.

"That's huge, because especially in lung cancer, that pretty much tells them that it had not spread within the chest or anywhere else. So they were able to target or design a treatment plan that was a little bit better for me," Prothro said.

Despite its value as a diagnostic tool, biomarker testing is not always covered by insurance. A proposed law this year at the Oklahoma Capitol would require Medicaid and private insurance groups to cover biomarker testing. Senate Bill 513 has been introduced, but has not yet been scheduled for a committee hearing, which is a necessary step in the legislative process.

"Are they denying people access to that now? Yes. Does the Legislature need to pass the bill? A thousand times, yes," Prothro said. "Because why wouldn't they? I mean, that's how I look at it. Why wouldn't you? If this is working, if people are living longer, if you know doctors can target your treatment plan based off of a simple test, why not?"

The old way of treating cancer involved flooding the whole body with poison and hoping the patient survives, said Ryan Poppe, a spokesman for the American Cancer Society. By comparison, testing for biomarkers is precision medicine.

"This narrowly tailors how we go about treating cancer, reducing like treatment times by 50% and increasing survivability by 60% in breast, colorectal and lung cancers," he said.

Insurance companies have complex internal guidelines for determining which medical procedures are covered. Those decisions are often based on whether the procedure or test is medically necessary, is part of the standard of care for a particular diagnosis, or is considered experimental or too costly.

Poppe said he hasn't noticed much if any opposition to the bill, but he expects health insurers will weigh in. Usually, he said, it's a question of whether a test or treatment is medically necessary.

"We feel like our data says this does reduce the overall cost to the state because it reduces the overall time someone has to be in treatment," he said.

After learning she had lung cancer, Prothro began volunteering with the American Cancer Society in Tulsa, and now works for the advocacy group in Dallas.

On March 27, she will have survived five years with her diagnosis. In that time she's faced chemotherapy, immunotherapy and surgery to remove parts of her lung. She's also outliving her diagnosis.

"Five years ago when they looked at my X-rays, I wasn't supposed to still be here. But I am, and I was given a chance and an opportunity that everybody needs," she said.