There’s little debate over the advantages of treating cancer with a pill compared to intravenously.
Conventional IV chemotherapy comes with a litany of side effects, often kills healthy cells along with cancer and must be administered in a medical facility. Oral chemotherapy, by contrast, has fewer and less severe side effects and can be taken at home.
How much that pill should cost is a different matter altogether.
Lawmakers are considering legislation making Missouri the 28th state to bar insurance companies from charging higher co-payments and deductibles for chemotherapy medication taken in pill form.
It’s an idea that has once again set the stage for a showdown between insurance companies, cancer advocates and the pharmaceutical industry.
Its supporters contend the legislation is simply about ensuring patients aren’t priced out of the best treatment available.
“Health care decisions should be in the hands of patients and their doctors instead of an insurance company,” said Rep. Sheila Solon, a Blue Springs Republican who has sponsored the legislation for three years.
Critics counter that the idea would cost insurers $12 million a year, a tab that would result in higher premiums for everyone.
“A mandate of this nature would definitely benefit the drug companies financially, but it would also result in higher insurance costs,” said Calvin Call, executive director of the Missouri Insurance Coalition.
Intravenous chemotherapy is usually covered as a medical benefit with flat co-pays and a cap on out-of-pocket costs. By contrast, oral chemotherapy is typically considered a pharmaceutical benefit, meaning patients pay a percentage of the drug costs with no out-of-pocket limit.
Because oral chemotherapy drugs are more expensive than intravenous drugs, that can end up costing patients tens of thousands of dollars a year.
“We were told by our doctor that an oral treatment would work, but the out-of-pocket costs were just too high,” said Ruth Perch of Oak Grove, whose husband saw his cancer return in his lungs last spring. He has been undergoing intravenous treatment since September at St. Luke’s East Hospital in Lee’s Summit. “It’s a real burden when you don’t live close to a hospital.”
Call said it’s “hard from a human standpoint to disagree with the idea of an oral medication replacing a more intrusive intravenous treatment.”
The question, he said, is how to pay for it.
“The drug manufacturers have disseminated the oral chemotherapy medication at a significantly escalated price compared to the traditional intravenous drug,” Call said. “They need to lower their prices and share in the expense if we’re going to make this work.”
Supporters point to an actuarial study commissioned by the legislature last year that concluded that insurance premiums would rise by only an average of 57 cents a month if such legislation were passed.
“That’s pennies,” Solon said. “Our concern isn’t the profit margins of the pharmaceutical industry. It’s providing the best care possible with the best survival rate for people battling cancer.”
But the pharmaceutical industry is certainly taking notice. In January, Celgene Corp., a drug manufacturer thathas advocated for so-called oral parity laws
, hired six new Missouri lobbyists.
Celgene did not respond to a request for comment.
The stakes are undoubtedly high. Around 30 percent of all new chemotherapy treatments for cancer patients are oral medications, so the trend is heading in that direction, said Carl Freter, director of hematology and oncology at the University of Missouri.
“Oral chemotherapy is the future of chemotherapy,” Freter told a Senate committee last week.
While insurance companies have been able to derail the legislation the last two years, Call said their goal now is to find a compromise.
One idea being floated would model Missouri’s legislation on a law enacted in Kansas.
The Missouri proposals include a provisionprohibiting insurance companies
from increasing the co-payment, deductible or coinsurance amount for an intravenous treatment in order to comply with the law.
That provision isn’t included in the Kansas law, raising the fear among advocates of cancer patients that instead of making oral chemotherapy more affordable, it could instead drive up the out-of-pocket cost of intravenous treatments.
“The Missouri legislation contains protections for the patient,” said Dee George, director of state government relations at the Leukemia Lymphoma Society. “The whole point is to make a patient’s out-of-pocket costs more manageable.”
Steve O’Neil, director of consumer assistance for the Kansas Insurance Department, said the law doesn’t regulate the price of drugs, just how much an insurance company reimburses. He said he’s not aware of any complaints that have emerged about how the law has been implementedsince it went fully into effect in 2011
Ross Nichols, a lobbyist for the Missouri Trucking Association, told senators that he was living proof of the need for better access to oral chemotherapy drugs. He was diagnosed with a brain tumor in 2011, he said, and oral chemotherapy has allowed him to be a “functioning person in society.”
“If I had to do the IV chemotherapy, there’s no way I’d be here testifying in front of you today,” Nichols said. “I’d have to be in a room in a hospital hooked up to something.”