The diagnosis from Elaine Fencl’s doctor was devastating. The 65-year-old Reynoldsburg woman had chronic myelogenous leukemia, a blood cancer.
But the news Fencl got from her pharmacist was almost a bigger blow. Her co-pay for a chemotherapy pill she would need to take every day for the rest of her life was $2,512.
“I just had a deer-in-the-headlight look. I asked for how many days, and (the pharmacist) said 30,” Fencl recalled. “I told her I’d have to think about it and walked out thinking, “We’re going to have to sell our house.?'”
Cancer treatment has changed in recent years. For many patients, taking a pill is easier, more effective and can cause fewer side effects than traditional intravenous chemotherapy, which often takes hours to administer through a patient’s vein at a doctor’s office or outpatient facility.
But health-insurance plans have been slower to change. Despite the advantages, cancer pills generally cost more. Paying hundreds or even thousands out of pocket is a problem for many patients, particularly retirees like Fencl and others on fixed incomes.
“We took some from savings; we cut back,” Fencl said. “We also have a line of equity on our house in case we need it.”
She and her husband spent $3,300 this year before getting approved for a prescription-assistance program. But that help recently ran out, and the couple must pay $450 a month for prescriptions the rest of the year and is preparing for a $2,750 charge in January.
A bill before the Ohio Senate would help cancer patients by requiring health-insurance policies to cover chemotherapy pills the same as traditional intravenous treatments. Specifically, it “prohibits insurers from providing less-favorable coverage for orally administered cancer medications.”
If approved and signed into law, Ohio would become the 28th state to enact oral oncology parity legislation.
“To me, it’s what’s best for the patient. It’s about giving them the best quality life possible. It’s also a fairness issue. Do we want people to live or not?” said Sen. Charleta B. Tavares, D-Columbus, who is co-sponsoring the bill with Canton Republican Scott Oelslager.
Cancer patients, their advocates and other supporters, however, are frustrated that the bill appears to be stalled for reasons unclear. It received only one hearing — in June — before the Senate Insurance and Financial Institutions Committee.
Chairman Jim Hughes, R-Columbus, acknowledged last week that the bill was forgotten while lawmakers worked on the state budget and other matters, but he pledged to hold more hearings, possibly as early as this week.
Both Hughes and Tavares said they are unaware of any opposition to the proposal.
In other states, some Republicans and insurers have opposed mandating what must be covered, arguing that such requirements would drive up coverage costs. Whether the same issues are raised in Ohio remains to be seen.
Miranda Motter, president and chief executive officer of the Ohio Association of Health Plans, did not return telephone and email messages seeking the organization’s position on the bill.
Generally, patients who get traditional intravenous chemotherapy on an outpatient basis pay a co-payment or flat rate covering the drug and cost of administering it. Under most insurance policies, annual out-of-pocket expenses also are capped.
By contrast, chemotherapy pills are considered a pharmacy benefit, and patients typically pay a percentage of the cost of the drugs, which can cost tens of thousands a year. Often, there are no limits on what patients have to pay.
“There has been an explosion of oral drugs for cancer in the last 10 years, but the laws, written many years ago, haven’t adjusted,” said Dr. Peter Kourlas, a Columbus oncologist and hematologist.
Chemotherapy pills now are used to treat numerous cancers, including lung, breast, lymphoma, colon and prostate.
The bill would allow doctors and patients “to choose the best treatment instead of medicine that’s affordable,” Kourlas said.
Traditional chemotherapy often kills both cancer and healthy cells while new oral medications target cancer cells and block their growth, said Dr. Jerry W. Mitchell, an oncologist and hematologist with the Mark H. Zangmeister Center in Columbus.
“Oral medications are often the preferred course of treatment, but cost is an issue. These can cost $10,000 a month. If you have a 10 percent co-pay, most of us can’t afford that every month,” Mitchell said.
“We’ve made cancer a chronic disease, but the challenge is when you make something a chronic disease, it gets very expensive to take care of.”
Marjorie Peirano has health insurance through her husband’s employer, but the Delaware couple will pay $10,000 this year for medications to treat the chronic myelogenous leukemia she was diagnosed with in 2011.
“It allows me to work, volunteer, and do everything I do with my family,” said the 51-year-old mother of two. “I don’t have to think about (cancer) and have a positive attitude. Everyone just wants to get back to how they were. If I didn’t take the pill, I’d be really, really tired, and get nauseous and all that.”
But Peirano frets about the cost. She and her husband have one daughter through college and are saving for the other, who will start soon.
“We’re lucky,” she said. “There are people who refuse it because they can’t afford to pay. I’m fortunate that we have enough for now.”
By Catherine Candisky - The Columbus Dispatch, Ohio (MCT)
©2013 The Columbus Dispatch (Columbus, Ohio)
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