Cancer treatment advocates are looking to reduce the cost to patients for oral chemotherapy drugs.
By Hyun Namkoong
Darrell Rhodes, 57, said he’d travel with a trashcan for the 40-minute car ride from the cancer treatment center in Greensboro to his home in Reidsville.
“On the ride home, I’d be throwing up,” he said.
Rhodes, an advocate for the American Cancer Society, was diagnosed with cancer of the throat and tongue in 2008. His insurance company told him he had to get intravenous chemotherapy and be hooked up to an IV machine for hours rather than swallow a chemotherapeutic pill and stay at home.
Many insurance companies in North Carolina treat oral chemotherapy pills as a pharmacy benefit, and this distinction means that the pills often aren’t covered in the same way as IV chemo, adding thousands of dollars to out-of-pocket costs.
Many patients who receive inpatient chemotherapy pay only the co-pay for hospital or clinic treatment. But if that same patient gets chemotherapy in the form of a pill, they often have to pay a much higher price for the drug.
Oral chemotherapy pills frequently have a much higher drug co-pay than an inpatient treatment, which is usually a price negotiated between the provider and the insurer. In some cases, the pills aren’t listed on the formulary of drugs covered by insurance companies, so the patient pays out of pocket.
And if the drug isn’t on the insurance company’s formulary, it won’t qualify as an essential health benefit, which means it won’t count toward the $6,600 cap on out-of-pocket costs mandated by the Affordable Care Act.
Rhodes said his oral chemo pills were two to three times more expensive than the IV option.
But the overhead of providing the chemo pill is much lower, said Bret Schaffner, who’s been receiving treatment for melanoma since 2008.
“You don’t have the costs to maintain an infusion center: power, lights, pump, nurse, IV bags. There’s a lot of overhead and you’re creating biohazard waste too,” Schaffner said.
He said patients who get their chemotherapy infusions at home must pay for a nurse and equipment, while the pill can be mailed to you.
Sen. Ralph Hise (R-Spruce Pine) said there’s movement in the Senate to file a bill to address the disparity.
“It’s overall a cheaper cost for the health care system, and particularly for Medicaid and other populations,” Hise said. “I think that requiring someone to come out with a greater out-of-pocket cost for something that is ultimately a lower cost doesn’t make sense for our health system and certainly doesn’t make sense for patients.”
Schnaffer also noted that many people who receive intravenous chemotherapy have to get a port implanted, creating a risk of infection.
“I think that oral chemotherapy is an incredible alternative for a lot of individuals,” Hise said.
Too many bills
Rhodes said the cost of the chemo pills was too much for him when combined with his other medical bills.
Thirty-four states and Washington, D.C. have passed legislation that requires insurance companies to cover chemotherapy treatments equally, with similar out-of-pocket costs.
Rhodes said the pills would also have reduced the burden on his caregivers. He had to rely on his mother or wife to drive 40 minutes, drop him off at the clinic at 7:30 in the morning and return to pick him up at 4. He believes that rural residents like himself would particularly benefit from the reduced cost of oral chemo.
Rhodes said he planned to speak with Senator President Pro Tempore Phil Berger (R-Eden) to explain why it’s important to have the treatments covered equally by insurance companies.
But he’s likely to meet opposition in the Senate. A similar bill, filed in 2013, passed the House by an overwhelming bipartisan vote. But there was no movement on the bill in the Senate, where there’s been little appetite for bills perceived as being insurance mandates.
When the bill was up for debate, Chris Evans, a lobbyist for Blue Cross and Blue Shield of North Carolina, called it an insurance mandate and argued that such mandates lead to rises in premiums for everyone. Evans also said this type bill puts little pressure on drug companies to reduce the high costs of the pills.
The bill hasn’t been filed yet this year and until it is, BCBSNC spokesman Lew Borman declined to speculate on it.
Christine Weason, government relations director of the American Cancer Society, said she expects the bill to be filed sometime next week by Rep. David Lewis (R-Dunn) and Hise.