Posted on 01/24/2012 6:41:34 AM PST by afraidfortherepublic
Thomas Van Hoof learned about the nuances of how some health plans cover oral chemotherapy drugs the same way most people do: He was diagnosed with cancer.
The cancer was multiple myeloma, and the treatment includes Revlimid, a drug that costs roughly $120,000 a year.
Revlimid is given orally, not intravenously, and the difference meant that Van Hoof's health plan would cover only half the cost.
"I said, 'Huh? This is our coverage?' " Van Hoof recalled. "That's when the jaw drops to the floor. That's the shocker."
The health plan covered chemotherapy drugs administered intravenously in a hospital or clinic. But Revlimid, available only as a pill, was considered a prescription drug, and his health plan covered only half of the cost of prescription drugs.
"It doesn't make any sense," said Van Hoof, a self-employed architect and real estate developer who lives in Shorewood.
State Sen. Alberta Darling (R-River Hills) is pushing for legislation that would change that.
Darling introduced a bill last year that would require health plans regulated by the state to provide similar coverage for oral and intravenous chemotherapy drugs. State Rep. Pat Strachota (R-West Bend) is sponsoring the bill in the Assembly.
More than a quarter of the estimated 400 chemotherapy drugs in development are in oral form, according to advocates. And Darling said the way insurance covers the drugs will become a more significant issue in coming years.
"You can't read your tea leaves or palm and determine if you are going to get cancer," Darling said.
The legislation is backed by a coalition of advocacy groups, such as the American Cancer Society and the Leukemia & Lymphoma Society, as well as Columbia St. Mary's Health System, Marshfield Clinic and the Medical College of Wisconsin.
(Excerpt) Read more at jsonline.com ...
Wisconsin Sen. Darling Doing Good Work Ping
If you want to be on, or off, this Wisconsin Interest Ping List just FReep mail me.
In your opinion, who do you think will pay for Sen. Darling’s “good work”?
One way to comply with this legislation of "similar coverage" will be to bill patients half the cost of IV drugs in the future.
The premium payers will pay.
In defense of this proposed change, it makes no sense to me to discriminate between drugs on the basis of the mode of delivery. Either all chemo drugs 50% co-pay or make them covered.
Obviously treating all chemo drugs as prescription medicines would save premium payers some money, but my bet is that most would prefer a slightly higher premium to know that these life-saving but expensive medicines would be covered 100% regardless of the particular drug indicated for the specific cancer as diagnosed.
I’d have to say, if I was a patient for any disease and found there was such a huge difference in price between two equally effective treatments, I’d go back to my doctor and ask to be prescribed the cheaper of the two instead. A far better solution than having legislators implement price controls.
The thing is not what type of treatment, but where it is administered. Insurance cos. pay more when treatment takes place within hospital or clinic walls. I don’t know why, but that’s the way it is.
If you read the article, you will find that the condition this drug treats is very rare. It is also paid for in most other states. Sen. Darling (a cancer survivor, herself) is just leveling the paying field for Wisconsin cancer patients. I’m sure that part of the added expense will be offset by patients not being forced to check into a medical facility to take their treatment. What does THAT cost — to take their drugs by IV, instead of self medicating orally? And who pays for that higher cost (which is approved now)?
Sen. Darling was subjected to recall herself last summer and the voters kept her in the legislature. Her Bill hasn’t passed; it has just been proposed.
For the record, this disparity is also present in some medical tests.
We know someone being treated for advanced, chronic Lyme’s. However, the test for Lyme’s in humans is not covered by this person’s very good insurance policy. It costs around $600 out-of-pocket. So, he has chosen not to get the test, but his physicians have chosen to treat him for the disease, anyway. The tx is covered.
It makes little sense, IMO.
Insurance companies have some screwy rules sometimes. We had to jump through some crazy hoops when my terminally ill great-aunt wanted to be moved from the hospital rehab facility to a hospice.
Anyway, this seems like a sensible piece of legislation to me.
Government regulation often creates perverse incentives, health insurance is very very highly regulated. As such tweaking the regulations so that they don't have a huge impact on the health and economics of patients is a good thing.
A better thing would be to deregulate insurance such that people can pick and chose which policies best suite their needs.
For example I would love a cheaper policy that doesn't cover herbal remedies, chiropractic, acupuncture, and any number of other pseudo-quackery procedures that Insurance - BY LAW - must cover.
Amazing that his physicians have agreed to treat him without the test. Prayers up for him (or her). It's one nasty disease.
Relax, if o-care become the law those types of charges will be eliminated for joe six pack and only those who mac daddy approves of will be able to get any worthwhile medical coverage.
Presto, another problem solved by the one, well not really he will have someone else do the dirty work in case thee is a problem and then he can always answer with his canned reply, “PRESENT”.
Developing testing and marketing a new therapeutic can cost upwards of a billion dollars.
Manufacturing some of these therapeutics can also be very expensive, not $120,000 per treatment, but costly.
It is not inhumane to offer a novel treatment at a price that reflects the cost it took to bring it to market. Before the novel treatment was offered patients ONLY had the choice of the less expensive, but also less effective treatment.
Offering a choice of treatments at a price that reflects the reality of the costs involved is a very humane thing to do.
The company I work for (developing novel therapeutics) offers “means tested” treatments such that those who don’t have the economic (or insurance) assets to afford our innovative and more effective treatment can get it at a reduced price.
But there is still the ‘old stand by’ treatment that doesn’t cost $120,000 that would be a patients ONLY choice if not for the “inhumane” companies that develop novel treatments. But then again that treatment often doesn’t work that well - thus the need for novel therapeutics.
Often times you get what you pay for.
If you are unwilling to pay for novel treatments then you don’t get novel treatments.
If the economic incentive to discover novel treatments is reduced or eliminated - so too will the pace of discovery of novel treatments decline in equal proportion.
It’s Big Pharma that offers treatments that cost $120,000 per year, in this case. They would answer “cost of research and bringing the treatment to market”. The difference here is that the IV treatment offered at the hospital probably costs as much when you count the cost of the room and equipment and medical personnel used to provide the treatment. The payment just goes to a different purveyor. What is not explained in this article is how long does the patient need the treatment. Is it a whole year? 2 years? 6 months?
I had a tumor removed last summer, and if I had also needed chemotherapy I would have taken Gleevec. Since it is administered in pill form rather than IV, the first thing I did was check to see if my insurance covered it as chemo or prescription drug. Fortunately, the surgery got everything and I have had no recurrence, and if I did, the $65,000 yearly cost of the Gleevec would be covered 100% under may plan.
Not to pry, but I’ve heard that Lymes is often misdiagnosed as MS. The MS is then managed while the Lymes progresses. Is that the experience of your acquaintance.
The insurance company and the pharma company will renegotiate the contra t for these drugs, resulting on one fewer gold faucets for the executive washroom.
No.
He is simply being treated for Lyme’s w/ infused antibiotics. He has multiple other health issues, has had a mitral valve replacement and a repaired patent ovale (congenital hole in the heart)and has Type II diabetes. He has had crushing migraines for years that cleared up for a while after his heart operations, but have returned.
The issue is solely that he doesn’t have an official dx of Lyme’s from a medical test, but is being treated as if that is the diagnosis.
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