Too often, cancer patients find that their health insurance falls short
McClatchy-Tribune Information Services -- Unrestricted
Cancer patients, even those who have health insurance, often face severe financial burdens at a time when their lives depend on fast, consistent medical care.
That's the conclusion of a report released Thursday by the nonprofit Kaiser Family Foundation and the American Cancer Society. The report profiled 20 cancer patients from across the United States.
Too often, patients with cancer and other serious illnesses are surprised to discover that their health insurance falls short of their needs, said Drew Altman, chief executive of the Kaiser foundation.
"The system seems to be failing most where it should be working best. And that's for people who are sick," he said.
Take Janice Virgil.
The 55-year-old Arlington nurse was diagnosed with breast cancer seven years ago and then had a recurrence in 2007.
Last year, Virgil tapped out all her available time off when she was hospitalized three times with allergic reactions to chemotherapy treatments.
"They finally got me on chemotherapy that I tolerated," she said, "but by then I had already lost my job."
Virgil kept up her health insurance through COBRA, but the monthly premiums climbed from about $60 to $462.
"I'm living off my savings account. And if you can imagine having three hospitalizations in three or four months, that was a lot of money," she said. "Insurance doesn't pay all of your bills."
Barry Russo, chief executive of The Center for Cancer and Blood Disorders in Fort Worth, said patients and their healthcare providers often must navigate a maze of potential resources to try to meet their expenses.
"It's the people who are chronically ill -- meaning their cancer is going to last for quite a while -- that really face these kind of issues," Russo said. "Once they have cancer and they've started the care process, we really can't interrupt it."
In Virgil's case, several charities have helped pay for her prescription drugs, physician costs and other needs. The cancer society, for one, bought her two specialized bras when she couldn't afford prosthetic devices after her mastectomy.
Even so, unexpected expenses pop up all the time, like when her arms swelled painfully with lymphedema after her surgery.
"None of my clothes fit. Well, I couldn't go out and buy new clothes," she said. There are "things you don't even think about that occur as a result of your disease. Insurance isn't going to pay for you to get new clothes."
Struggling to get coverage
Thomas Olszewski, a retiree from Graham, northwest of Fort Worth, who was profiled in Thursday's report, had little trouble paying for his prostate-cancer treatment. For him, the serious problems began afterward, when he tried to buy individual health insurance.
Olszewski, 62, who has been cancer-free for almost 10 years, said insurers still want to charge him prohibitively high prices. And some refuse to sell him coverage at all.
He finally landed a health plan that leaves him responsible for most of his routine bills -- a situation that feels a lot like having no insurance at all.
"The deductible is $3,750," Olszewski said. "And other than the discount you get because of their physicians network, there is no coverage until you reach the deductible."
He has responded by cutting back on his medical care. One example: He has a follow-up prostate test every two years, instead of annually as his doctor recommends.
"When you go to the doctor, they automatically assume you've got insurance: 'You can cover this $500 drug bill. I want to do $500 worth of tests. Oh, let's do a cardiac test on a treadmill. That's $1,000,'" Olszewski said. "I don't go to the doctor at this point unless it's absolutely an emergency, because there's no money for it."
Chipping away at debt
Janice Cabral, 45, has been able to hang on to her job and her employer-based coverage. But that hasn't been enough to keep the White Settlement woman out of financial trouble.
When Cabral was diagnosed with breast cancer in 2007, she promptly emptied her 401(k) account, gave up her apartment and moved in with her brother.
She kept her job working with mental-health patients, taking almost no time off since her treatment -- although she did give up additional part-time work when the chemo side effects became unbearable.
"I just couldn't do my second job," she said. "I was stopping at carwashes and vomiting in trash cans."
Cabral's health plan paid most of the bills, and a nonprofit organization's grant helped cover some of the rest. But she said her expenses still piled up.
More than $2,000 to her surgeon, $658 for a biopsy, $369 to the plastic surgeon, $401 for lab tests, $1,097 for another surgery, and on and on.
Cabral chips away at the debts, but some of the bills have been turned over to a collection agency.
"Thank God for my brother letting me move back in and use his credit card, because I probably couldn't have met my deductible," she said. "I was one of the lucky ones. I got the grant. I had medical coverage, and I had family who helped me out tremendously. And now, I just plug away at the rest of it."
Among the key findings in the report "Spending to Survive: Cancer Patients Confront Holes in the Health Insurance System":
Cancer patients who become too sick to work can face catastrophically high medical bills. Patients who leave behind jobs with employer-sponsored health insurance can continue that coverage for up to 18 months through the government's COBRA provisions. But paying the full monthly premium can be a steep burden at a time when their income has been slashed.
A variety of restrictions in insurers' health plans can leave cancer patients vulnerable to high out-of-pocket costs. Many patients are forced to meet hefty annual deductibles and to contend with caps on yearly benefits and lifetime limits on coverage -- all thresholds that can be reached quickly during expensive cancer treatments.
It's difficult for cancer patients and survivors to buy health insurance individually, because insurers typically charge them high premiums or refuse to cover them altogether.
Some states, including Texas, offer "high-risk pools" that provide insurance to cancer patients and others who can't buy coverage elsewhere. But these health plans are much more expensive than the insurance available to other consumers.
Many cancer patients become eligible for government programs, such as Medicare and Medicaid. However, those programs have long waiting periods and other restrictions that can leave them without affordable health coverage for long durations.
Rising Cancer Drug Costs Not Fully Controllable Under Medicare January 29, 2009 (Reuters Health) - Last Updated: 2009-01-28 16:05:02 -0400 (Reuters Health)
NEW YORK (Reuters Health) - Current regulations are limiting Medicare's ability to control rising spending on cancer drugs, concludes the author of a Health Policy Report published Online First (January 28) in The New England Journal of Medicine.
Fifteen years ago, the only commonly used cancer drug on the market that cost more than $2,500 per month was Bristol-Myers Squibb's paclitaxel, notes Dr. Peter B. Bach, from the Health Outcomes Research Group, Memorial Sloan-Kettering Cancer Center New York, and a former senior policy adviser to the Centers for Medicare and Medicaid Services. "Today, cancer drugs that come on the market routinely cost many times that amount."
In part because of rising prices and in part because of increased rates of use, spending on cancer drugs has skyrocketed, Dr. Bach notes. Spending on Medicare Part B drugs, a category dominated by anticancer agents, increased from $3 billion in 1997 to $11 billion in 2004 -- an increase of 267%. By comparison, during the same period, overall Medicare spending rose 47% -- from $210 billion to $309 billion.
"The strong upward rise in cancer-drug prices and spending has provoked concern on several fronts," Dr. Bach writes. "Health economists are concerned, too, both by the rising expenditures for cancer care and because the prices of cancer drugs appear to be rising faster than the health benefits associated with them, at least in some cases."
Dr. Bach believes the growth in cancer-drug prices and spending "can be attributed primarily to a unique legislative and regulatory framework that shields cancer drugs (as well as other specialty drugs) from the strategies that health care payers such as Medicare typically use to hold down the price and utilization of drugs and other health care goods."
Policymakers are now in a quandary, Dr. Bach says. They are faced with finding ways to rein in drug costs and spending without stifling innovation and progress on cancer care.
"One possible approach," Dr. Bach says, "is to judiciously amend or reverse the laws that limit Medicare's flexibility with respect to cancer drugs, while moving rapidly toward the creation of a center for comparative effectiveness that could guide Medicare's actions. Such a center could help Medicare ensure that cancer drugs are covered when their use is reasonable and necessary but are not covered when they are not."
This center could also create a framework for classifying drugs as interchangeable when they are, basing the judgment on clinical rather than pharmacologic criteria. This would likely prompt manufacturers to conduct clinical research to prove that their drugs are not interchangeable with other drugs on the market. "Meanwhile, Medicare and other payers could apply formulas for reimbursement that would encourage lower prices when products are in fact clinically interchangeable."
N Engl J Med 2009;360.