Wisconsin Legislation Addresses Cost Disparity in Cancer Treatment

Dr. Jerry Mitchell Winkler, an oncologist at the Green Bay Oncology clinic, doesn’t handle every cancer case the same. Treatment depends on the type of cancer, the patient’s strength and the patient’s insurance.

That’s because cancer medicine can be delivered in different forms – mainly through an IV or a pill. Those two forms of treatment are covered under different aspects of traditional insurance plans. Pills are covered as pharmacy benefits, and IVs are covered as medical benefits.

With medical benefits like IV cancer treatment, there is typically a limit on out-of-pocket costs. With prescription drugs, patients often pay a percentage of the cost for every pill and never hit a ceiling for the amount they spend to cover their medications.

That means patients fighting cancer with pills sometimes have to pay more than those fighting cancer with IV treatment.

“It doesn’t matter who you are or where you work when you have to pay 50 percent of one of these medications on an ongoing basis,” said Lori Schneider, business office manager at Green Bay Oncology. “We do have people say ‘we can’t afford that, we just can’t be treated because we just can’t afford it.’”

Pill medications are often easier on patients, and sometimes are the most effective or only method of attacking cancer cells. Winkler said the cost disparity is the result of insurance coverage not adapting to advances in cancer treatment.

“Cancer treatment has so dramatically changed in the last 15 years,” he said. “Forty years ago, a cancer plan that wanted to cover people for just about anything they may have would cover almost entirely IV medicines. Starting in the late ’90s that began to change with the advent of molecular and targeted drugs [that come in pill form].

It really is because of an older concept of what the treatment of cancer is, that it’s all on IV. Most people are surprised by how much we can actually do with pills now.”

Winkler and Schneider estimate the cost disparity affects a few hundred new patients every year that come to their clinic – one of three clinics in Green Bay. That’s hundreds of cancer patients who forgo treatment, choose a less effective treatment or a less comfortable treatment, or pay sky-high prices for pills.

“It really comes down to an issue of justice and how society’s going to decide what’s fair,” Winkler said. “Society’s tried not to have an opinion so far.”

Cancer Fairness Treatment Act

A Wisconsin bill called the Cancer Treatment Fairness Act wants to address the cost disparity in cancer treatment. The bill would prohibit health insurance policies that cover cancer treatment from requiring patients pay more for pills than IV medicine.

The bill is endorsed by the Leukemia & Lymphoma Society, the Wisconsin Association of Hematology and Oncology, the American Cancer Society and many other cancer advocacy groups.

But Rebecca Larson, executive director of the Alliance of Health Insurers, doesn’t support the legislation. She said the real problem is the rising cost of medications, not coverage.

“Legislative mandates that dictate plan design hinder creative solutions to the affordability and accessibility of health care,” Larson said in an email. “Because the cost of prescription drugs can be high, the health insurance market has created a variety of benefit designs to meet the needs and budgets of consumers. The market should decide the solution, not mandates by policy makers.”

Larson said Alliance of Health Insurers members already cover oral cancer treatment.

Although he’s optimistic about legislation, Winkler was skeptical about how it might affect insurance premiums.

The bill was referred to the Assembly Committee on Health on Sept. 26, and had 41 representatives and 15 senators on board as of Oct. 2.

Affordable Care Act

Larson said the Affordable Care Act will address this issue, since it requires insurance to cover “essential health benefits,” including prescription drug coverage.

“The benchmark plan chosen for Wisconsin (the standard benefit plan all insurers must follow going forward) includes coverage of oral chemotherapy medications,” she wrote. “Therefore, if a plan did not cover this benefit in the past, it will need to do so going forward.”

But with the congressional fighting over the implementation of the Affordable Care Act, which played a role in the federal government shutdown, it’s hard to say what healthcare coverage will look like in the future.

Whatever happens, Winkler said it’s important we provide equal access to the best forms of treatment – no matter the form.

“We’re trying to learn to treat cancer smarter, better, more conveniently and with less toxicity,” Winkler said. “That’s always been the move. It’s hard to conclude that that’s not where it’s going.”