Insurance coverage starts to embrace clinical trials for cancer

(Written by Sr. writer Jill Mckellan, www.Lazarex.com)

Many states have started to be more embracing to cancer clinical trials in regards to their insurance coverage.  This is a positive sign for every individual who is undergoing an epic battle with cancer and wants to be a part of the solution.  They become part of the solution by hopefully going into remission and helping the brightest scientists find a way to stop cancer dead in its tracks.

Does this scenario sound familiar?
You’ve heard the sad stories.  Somebody is diagnosed with cancer.  They have two choices:

•  Receive the standard treatment
• Qualify for a clinical trial

Most insurance companies are not receptive to the cancer clinical trial route.  They want their policy holders to go with proven treatments – even when they have not necessarily been proven to be effective.  Clinical trials seem way too risky in many insurance companies’ eyes even though they may hold the key to reducing insurance costs down the road.  That doesn’t sound logical, but it is true.  They will not cover standard medical care for cancer patients if they choose to participate in a clinical trial.

People with cancer, their families, and those who wish to help find a cure have taken on the battle against big insurance opposing cancer clinical trials.  Their complaints have been heard by most states now and change is slowly starting to take place.  What does this change mean for people who need it?  It means there is hope on the horizon.

What can the states really do?
States do have the right to be proactive and adopt laws or other “formal agreements” that require insurance companies to handle the cost of routine care for its policy holders that have been diagnosed with cancer.  These changes slowly started to take place in the late 1990’s in several states out East (Rhode Island, Maryland, and New Jersey).  Soon after those states implemented cancer patients rights in regards to insurance coverage Medicare and the U.S. Department of Defense’s TRICARE health insurance plan.

Different protection actions such as the Patient Protection and Affordable Care Act have played a role in bringing awareness to insurance companies that don’t necessarily look out for all their policy holder’s best interests.  The PPACA brought stipulation to insurance companies that require them to pay for routine costs of care delivered in Phases I through IV of clinical trials.  This also includes trials that are preventative and early diagnostic purposes.

What is a “routine cost”?
Routine cost is a term that is about as broad and non-committal as one could ever hear.  The PPACA said that routine patient costs in clinical trials that health insurance providers must cover are all items that are consistent with what a cancer patient would receive if they were not in the clinical trial.  These covered items typically include:

• Hospital visits
• Imaging
• Laboratory tests
• Medications

There are a few things that PPACA does not cover though.  The items excluded from the act are:

• Investigational treatments, devices, or the service itself.  Those expenses are to be covered by the group that is conducting the trial (or the trial sponsor).  Many times this group may be the National Cancer Institute or a pharmaceutical company.
• Data and services that are collected just for record keeping and analytical needs.  They are not used in direct clinical supervision of the cancer patient.
• Services that are obviously inconsistent with the most widely accepted practices and established standards of care for a particular diagnosis.

Does the new health care reform affect cancer clinical trials?
The new health care law, as it stands, does offer a baseline of coverage that all 50 states and the District of Columbia must adhere to.  It should plug some of the gaps in existing state laws and agreements.  One of the requirements in it is that coverage for routine care costs for clinical trial participants in “self insured” plans should be more consistent.  A self insured plan is considered one that is paid for solely by an employer.  As of right now, these self insured plans are not regulated by every state due to other legislation that exists.

What do the states say about insurance coverage for patients in clinical trials?
New Jersey, one of the first states to have required insurance coverage agreements for individuals in clinical trials for cancer, has said that the experience has been very positive.  This is according to Dr. Susan Goodin who is a director of clinical trials and therapeutics at the Cancer Institute of New Jersey.  She also said that there were no problems with any of the insurers when it came to covering the standard of care that insurance policies covered for non clinical trial cancer patients.  They don’t pay for the research and if the study requires extra CT scans and blood work they pay for them.  The insurance pays for what they would have if a patient was not part of the trial program.

As the demand for cancer clinical trials increases there is no other option left besides bringing people together.  Everybody agrees that they’d like to eradicate cancer and that cancer clinical trials are the start of achieving that goal.