New state law covers Chemo treatments equally

Jan 11, 2012

With the new year came a new state law benefiting cancer patients across New York.  The law requires health insurance plans to cover chemotherapy, no matter how the treatment is administered. 

Newer oral chemo pills must now be covered "no less favorably" than traditional intravenous treatments

"I was diagnosed with chronic myelogenous leukemia, which is abbreviated CML, in January of 2009," said Bonstein.

Megan Bonstein was a 24-year-old social work major at Columbia University when she was diagnosed with leukemia.  Now 27, she takes the oral chemotherapy pill tasigna  every day to keep her blood cancer from re-occurring. 

"It's typically over $10,000 if you're uninsured and you're just purchasing the drug. Obviously, that's way above and beyond what anyone I know would be able to spend,"  said Bonstein.

Bonstein's health insurance covered only the first month of her tasigna, a treatment she expects to be on for the rest of her life.  She's been getting the drug through the manufacturer's patient assistance program, but that's not an option for most. 

Nancy Hails, Executive Director of the Leukemia and Lymphoma Society of Western and Central New York, says cost is a barrier to treatment for many cancer patients. 

"A study found that one in six cancer patients with high out-of-pocket costs abandon their medication.  If their out-of-pocket costs were greater than $200, they were three times more likely not to fill their prescriptions," said Hails.

In fact, cost influences how and whether patients take many different kinds of prescriptions.  But oral chemo is not just any prescription.  Cancer is one of the most common chronic diseases in New York State, second only to heart disease as the leading cause of death.  Each year, about 100,000 New Yorkers are diagnosed with some form of cancer and, for people like Bonstein, it can be a life-long challenge.

"I am just really thrilled that so many people worked so hard and really pushed for this. I'm very grateful to that dedication from so many that really helped make this possible," said Bonstein.

Martin Burruano, Director of Pharmacy Services for Independent Health, says the new law helps insurance coverage catch up to advancements in chemotherapy.

"Really the impetus behind this is this law was the fact that they were all intravenous, physician delivered, administered.  Now there's more and more oral therapies coming to the market.  So the law wanted to ensure that they were on parity cost-wise as the medical because these drugs are so expensive, so the patients can afford them," said Burruano.

"It seemed a very irrational situation where the insurance will cover the treatment if they came to the clinic and got the I-V, but if you wrote the prescription for them they didn't cover it or they covered it only partly," said  Dr. Alex Adjei  Chairman of the Department of Medicine and Senior Vice President of Clinical Research at Roswell Park Cancer Institute.  He said the high cost of oral chemo has influenced treatment decisions.

"As physicians, we've always prescribed them because that's the best treatment for the patient.  But unfortunately, then, sometimes we're forced to use something else because the patient couldn't get coverage for it and couldn't afford it," said  Dr. Adjei.

Now that cost is less of a barrier, he expects oral chemo prescriptions to increase.  The New York Health Plan Association opposed the state's new law, saying it would reduce patient access and safety, while increasing the cost of health insurance. 

But Dr. Adjei said patients who are properly instructed to self-administer oral chemo at home not only saves time and money for patients, but for the overall health care system.

"For an intravenous drug you have to come to hospital, you have nurses, you have pharmacists.  There are I-V needles, the bottles you give it in.  So they're actually, a lot of times, more expensive because the administration requires all kinds of time from health care personnel that you have to account for.  Whereas an oral pill, you get your prescription and you take it at home,"  Dr. Adjei.

Hails said the change will cost most health insurance plans under 50-cents per member per month.  

At least 12 other states and the District of Columbia now require intravenous and oral chemo to be covered equally, and bills are pending in more than 20 other states.  Congressman Brian Higgins has introduced a similar federal bill to encourage equal coverage nationwide.

"Medical advancement is no good to anyone unless it's accessible to everyone.  The fact of the matter is that too many people are dying from cancer, so morally and otherwise, I think it's very, very important to advance a change of the insurance paradigm so that it keeps pace with scientific and medical advancement, without which, it doesn't do anybody any good," said Congress Higgins.

Higgins said today we're talking about cancer, but tomorrow we may be talking about treatments for other diseases that are covered by health insurance based upon their purpose instead of their form.