What would you say if your chances for successful cancer treatment depended largely on your ZIP code? That’s what happens in England, where patients are at the mercy of the health care resources available in their immediate geographic area.
Want the latest cutting-edge diagnosis and treatment? You’d better hope the local oncologist has had time to read some journal articles or attend a conference or two. Need to have a complicated tumor removed? You’d better hope your local general surgeon is up to the job.
Now replace “ZIP code” with “insurance policy” and you’ll better understand what’s happening in the United States. One of the harsh lessons people with cancer have learned from the Affordable Care Act is that “having health insurance” isn’t the same thing as “having access to health care.”
Consider NBA great Kareem Abdul-Jabbar. As it turns out, his toughest fight wasn’t on the basketball court.
In his early 60s, the six-time NBA champion was diagnosed with leukemia. Fortunately, Abdul-Jabbar had access to state-of-the-art medications, including the advanced drug Tasigna (nilotinib), which stopped the growth of his cancer. Today, eight years after his initial diagnosis, he is cancer-free and thriving. Is your insurance as good as Abdul-Jabbar’s?
Unfortunately, many people with leukemia won’t be so lucky. CVS Health—the nation’s second largest pharmacy benefit manager, which oversees the drug plans of 65 million Americans—recently rescinded coverage for Tasigna and 130 other specialty drugs.
As a result, millions of people could be denied access to therapies that could save their lives. Instead of prescribing the medicines best suited to patient needs, physicians will be forced to recommend treatments on the formulary.
Pharmacy benefit managers, or PBMs for short, administer prescription drug plans offered by employers and health insurers. In recent years, these organizations have gotten stingier about which drugs they will cover.
Back in 2012, the nation’s largest PBM, Express Scripts, excluded no medicines from its list of covered drugs, while CVS Health left off about 30. Today, they both exclude more than 200, including some cutting-edge cancer treatments.
Anyone who paid attention to President Trump’s May 2018 press conference or read the White House “Blueprint to Lower Drug Prices” understands that drug pricing involves a whole ecosystem that includes manufacturers and multiple intermediaries. Games are being played, and patients are generally losing.
Drug coverage denials are a deadly prescription for people with cancer. It’s about time for a full-court press against this callous behavior.