Missouri legislators weigh coverage of anti-cancer drugs
01/16/2014 7:40 AM
01/16/2014 7:40 AM
Treating cancer with a pill is more convenient and has fewer side effects than intravenous chemotherapy, cancer patients and their advocates say.
Now, they hope to make it more affordable as well.
A bill filed in the Missouri Legislature would bar insurance companies from charging higher out-of-pocket costs for oral anti-cancer medications than for intravenous medications.
The bill’s supporters say that oral chemotherapy targets the cancer cells better, causes less nausea and avoids the possibility of an infection at the infusion site. Taking the medication orally also allows patients and their caregivers to avoid traveling several times a week to get treatment.
“It gives people a little more of their life back,” said Dr. Rebecca Lueckenhoff, of Jefferson City, who was diagnosed with a brain tumor in 2008.
But although intravenous chemotherapy is usually covered as a medical benefit with a flat co-payment, oral chemotherapy is generally viewed as a pharmacy benefit. Because patients must pay a percentage of the drug’s cost, they can face bills that exceed thousands of dollars each month.
Lueckenhoff said she drained her savings account to pay for the cancer pill Temodar before she eventually got financial help under a program run by the drug’s maker.
This is the third year that Rep. Sheila Solon, R-Blue Springs, has introduced the bill — HB1327 — requiring “parity” for oral and intravenous treatments. Though it has been killed by insurers’ opposition in the past, she said Wednesday that she was hopeful. Her bill has 52 co-sponsors, representing both political parties.
Giving the bill added steam: an actuarial study commissioned by the Legislature last year. The study, by Lewis & Ellis of Overland Park, Kan., concluded that requiring parity for oral anti-cancer medication would cost, on average, 57 cents a month for each insurance policyholder.
“The increase in premiums, if any, is minimal,” Solon said at a news conference Wednesday.
Twenty-seven states and the District of Columbia have passed parity laws.
Whether Missouri follows suit could hinge on whether the proposal is viewed as imposing a new insurance benefit.
Insurers say the proposal would cost the industry $12 million a year and state taxpayers could be on the hook for the tab.
The federal Affordable Care Act provides for a package of “essential health benefits.” If states require benefits that are not included in the package, the state must pay for those benefits for people enrolled through the federally run insurance exchange.
Is requiring access to oral chemotherapy a new benefit if an insurer already covers cancer treatment?
Yes, say insurers.
“It’s a mandate and it’s going to be an increased cost,” said Calvin Call, executive director of the Missouri Insurance Coalition.
No, says the federal Centers for Medicare and Medicaid Services.
In a question-and-answer memo released last August, the agency said: “We do not consider such payment parity bills to create a requirement to cover a new benefit.”
A court is likely to get the final word.
“Nobody has a clear indication that this would not be subject to state responsibility, because it’s not been tested,” said David Smith, who lobbies for Anthem Blue Cross Blue Shield of Missouri. “Ultimately, a judge is going to decide that.”
House Insurance Committee Chairman Chris Molendorp, R-Belton, said he used to oppose the bill but was now looking for middle ground.
“What we’re discussing is the delivery of the treatment,” not mandating a new benefit, he said.
If the law isn’t changed, Missouri could deny an increasing number of patients access to newer therapies, the bill’s supporters say. About 25 percent of the 400 chemotherapy drugs under development are oral.
Oklahoma passed a parity law last year, Oklahoma state Sen. Greg Treat, R-Oklahoma City, said. He attended the proponents’ news conference in the Capitol and said he had talked with dozens of Missouri legislators to urge them to become the 28th state.
“We pass things every day,” he said. “This one, you know it’s going to affect peoples’ lives.”
Jo Ann Shaw of St. Louis, chair of the Gateway Chapter of the Leukemia & Lymphoma Society, said she had endured decades of intravenous chemotherapy for four kinds of cancer. She said she lost her hair and had scars from surgeries and ports used to inject the drugs.
“I don’t want another little girl or boy to go through a life of having to be hooked up to a port, losing their hair,” she said. “You don’t have those side effects with the oral. Some people have a little nausea, but it’s not ‘Stop the car.’ It’s not constant vomiting. The key here is to give patients and physicians a choice.”