Several US states are planning to follow the example of Oregon, which has introduced a law requiring health insurers to provide cover for oral cancer treatments as well those given intravenously.

Drugs in pill and capsule form currently account for less than 10% of all cancer treatments, but this share is expected to increase to 25% within the next few years, enabling patients to lead more normal lives as frequent visits to the clinic for iv treatment will no longer be required. However, these developments are causing problems for both patients and physicians, reports the New York Times (NYT).

Health insurers generally pay for iv cancer drugs as a medical benefit, but oral treatments are usually covered by prescription drug plans which, for expensive therapies, can present the patient with very large co-payments and annual coverage limits. For example, the federal Medicare programme's prescription drug benefit, which covers seniors and disabled people, pays 75% of prescription drug costs (after the first $295 deductible) until total spending reaches $2,700. After that, the “doughnut hole” kicks in, during which the patient has to pay the full cost of their prescription drugs until the annual total reaches $4,350, after which Medicare’s “catastrophic coverage” provision takes over, paying most of the patient’s covered prescription drug costs for the remainder of the year. For patients receiving innovative new cancer drugs, the doughnut hole can be reached very speedily.

The Patient Advocate Foundation, which helps patients with their insurance co-pays for cancer drugs, says that 56% of the cases it dealt with last year involved oral treatments, even though far more patients receive iv drugs, reports the NYT. Moreover, there are no iv equivalents for most of the new oral cancer drugs.

Cancer doctors are also facing a number of issues. For example, they are less able to check that patients on oral treatments are taking them as prescribed, and they make no profit from drugs which they prescribe but are dispensed at a pharmacy. They are also facing financial problems as cancer treatment has moved away from large medical centres and into the community.

84% of US cancer patients are now able to receive accessible care on an outpatient basis, and while this has been “a tremendous success…we are now seeing that infrastructure beginning to crumble,” says Dr Patrick Cobb, president of the Community Oncology Alliance (COA).

Oncologists have to purchase the drugs ahead of time, which is a “huge economic risk,” he said. Before the Medicare Modernization Act of 2003, they were reimbursed for them based on average wholesale prices, with overpayments which helped subsidise a range of associated cancer services. However, the new system set up under the MMA, based on average selling prices, has never been implemented, with the government providing stopgap funding during 2005-6 which expired in 2007.

- Oregon’s law requiring health insurers to provide equivalent coverage for intravenous and oral cancer drugs took effect in late 2007, and other states considering a similar measure including Colorado, Hawaii, Minnesota, Montana, Oklahoma and Washington, the NYT reports.

Most doctors “pressured by insurers to substitute”

Meantime, a medical association says that more than four out of five of its members feel “pressured” by insurers and managed care plans to substitute the drugs which they have prescribed for patients with other, cheaper products.

Commenting on the findings of the Michigan Osteopathic Association’s survey of 500 doctors, group president Dr Craig Magnatta urged patients to ask their pharmacists if the medicines which they receive are those prescribed by their doctor and to ask, if they are not, why the substitution was made. They should also ask the pharmacist to tell them about side effects related to the ordered drug and to inform their doctor that the prescription was declined, he added.