Insurance companies cooking up ways to standardize cancer care:

KittyKitty

http://finance.yahoo.com/news/cancer-drug-costs-unsustainable-according-153200242.html

What this means is that they want to create "standard treatment plans."

I think we all know what that means.

otter

I'll admit it:  my first reaction to this thread was not what the O.P. was hoping for. 

I thought, "Yeah, sure... what's wrong with basing treatment plans on 'evidence-based medicine'?  What's wrong with some standardization of treatment plans if there's no evidence that a more expensive regimen would offer any medical benefit?  Maybe standardization of regimens would decrease what sometimes seems like a haphazard approach to cancer treatment, where 6 different treatment protocols are used on 6 women whose tumors have identical characteristics?"

Right.  Then I read the article more carefully. 

This could be scary stuff, for those of us whose doctors took an unconventional approach.  For instance, my onco agreed to use Taxotere/Cytoxan instead of Adriamycin/Cytoxan on my ER+ PR- tumor.  And my BS ordered a breast MRI to screen for additional tumors in my very dense breast tissue.  That's not "unconventional" in the complementary medicine sense; but it's likely that standardization of treatment plans would have resulted in many of us being treated exactly alike, despite our docs' reservations.

Also, I don't mind participating in clinical studies, as long as the process requires "informed consent."  (I expect to be given the right to decline.)  Based on my reading of the article, it looks as if one purpose of adopting "standard treatment plans" is to gather data on the effectiveness of those protocols (Re:  " '...With greater consistency in treatment, we can begin to do real time comparative effectiveness research,' said Lee Newcomer, MD, SVP, Oncology, Genetics and Women's Health, UnitedHealthcare.")  It is hard to compare treatment protocols when everybody is treated slightly differently (6 rounds of chemo vs. 4; Taxol vs. Taxotere; anastrozole vs. Aromasin; etc.).  The numbers aren't there for a reliable statistical analysis to compare effectiveness.  So, would this be a covert attempt to conduct "research" on patients without their consent?

I do think doctors ought to stay up-to-date, and I do support "consensus-based" treatment plans.  I do think our docs ought to base their treatment recommendations on proven protocols, and not just their personal opinion or their limited observations.  But, it worries me that someone other than my doctor might be deciding what the "proven protocol" will be.  I also think our docs ought to be able to deviate from the "consensus" protocol if there is evidence that a particular patient might benefit from a different approach.

We hear a lot about "individualized treatment plans," and especially about the near-uniqueness of our tumors at the genetic level.  "Standardized cancer care" takes us in the opposite direction.

otter

1Athena1

It's only a report about a discussion in a webinar that gathered insurance company people. In other words, it's just chatter.

Insurers and health plans ALREADY put limitations on what care they will or will not cover for all sorts of diseases. This feudal system of ours already encourages rationed/top down "one-size-fits-all healthcare. I don't see new reason for concern here - it's all part of the same thing.

KittyKitty

Otter: "We hear a lot about "individualized treatment plans," and especially the near uniqueness of our tumors at the genetic level. "Standardized cancer care" takes us in the opposite direction."

Exactly my thought.

Standardized cancer care would fit people into broad categories, and then it will be up to the patients and their doctors to appeal the insurance company "guidelines" to get the health care they really need.

dogeyed

You know, tho, this thread brings up an interesting issue.  Insurance companies trying to get in the middle of what docs are doing, really upsets me.  And then there's pharmaceuticals who charge unreal amounts for this shot or that chemo infusion, and there's hospitals and clinics who do this too, and this is becuz they know they'll get paid for it, whatever they charge, so they go all out when they know it's a covered expense by an insurance company.  And THEN there's this problem I ran into that I still haven't cleared my mind enough yet to do something about it, but when my treatments were over, HOW COME my doc didn't request a CT scan?  Why DID I HAVE to be the one, and even then it had to wait until almost a year later.  I hear other girls getting their scans.  My brother about jumped out of his skin on that one.  And I just KNEW it had to do with whatever deal the clnic has with the insurance people.  SIGH. 

You know, I just gotta say this, but Democrats have been trying SO HARD to give us national health care, just like every other country has in the world excepting us, where President Obama said we need well people, not how many people can a doc see in an hour.  I mean, Repubs talk about free market of insurance companies, but I say what about free market of keeping folks healthy and alive!  Doesn't that get a vote?  Doesn't THE PATIENT have some weight anymore?

riverhorse

From what I understand about the Affordable Care Act it will determine what sort of treatments are most effective for most people -- while there is now no cost effective mandate, if it follows the path of NICE in the UK that would be the logical next step.  Just for instance, NICE will not cover Oncotype testing for two reasons, not completely clinically proven and not cost effective.   I would rather have insurance companies at least competing for my premium than the government deciding what is the most cost effective treatement for the largest part of the population.  As you all so rightly point out, breast cancer is a mulitfacted disease and there is no one size fits all treatment.  When we are talking about government provided goods or services the most efficient use of a scarce resource (money or medicine) is to use it where it will deliver the greatest benefit to the largest number of people.  I think if we wind up with a national health care system  breast cancer patients will be looking back at the good old days when they fought with insurance companies and not with government officials who do not have to worry about consumer satisfaction. 

1Athena1

I really don't understand what the unnecessary alarmism and hoopla are about here. This is NOT  new and it has NOTHING to do with the Affordable Care Act. Could people please hold their horses. This is starting to look like the privacy thread - a chain reaction in which people panicked partly because they didn't read carefully.

Insurance companies ALREADY make decisions about what cancer care and what other medical care they will pay for. NOTHING NEW!! They have made such decisions for US consumers for years, and they have made it about ALL diseases (which is why I go private for much of the treatment for my comorbidity).

The Affordable Care Act has NOTHING to do with the OPs article, which was simply a post about a webinar discussion. It has NOTHING to do with health reform policy.

It has NOTHING to do with NICE - although, BTW, the Oncotype test is rather unproven, so they are right about that.

Again, folks, please read carefully. I am starting to half-understand Day's frustration in the privacy thread.

Some people just love raising alarms all over the place, it seems.

We have enough to worry about here - er, namely our cancer.

Off river water and tongue box (lions don't use soap :-) )

Wabbit

Everybody does understand that the ACA establishes a pool of private insurance plans?  It will be private insurance companies offering their plans and competing for your $$$.

And in my opinion the patient is already the low man on the totem pole now.  Medicine and insurance are businesses and making money is the name of the game.  So although I think individual doctors try to do their best for their patients, the business environment they have to work in (around) is becoming an increasing problem.  The bean counters are making too many medicial decisions and have been for many years.

It is possible that some standardization might prevent some of the least ethical insurance companies from denying certain treatments also.   Not ready to jump off any cliffs here just because they are talking about it.  Talking about it is good IMO.    

riverhorse

Sorry to upset everyone. But I think the ACA will determine the extent of coverage insurance companies are obliged to provide. I think there is some sort of board that will examine the effectiveness of various treatments. I do think there is cause for concern and I do not think it possible to separate the issue of health insurance from the ACA. I think people with diseases that are very expensive to treat are wise to pay close attention to what is coming next. But that is just my opinion. Easy to ignore if it is disturbing

1WonderWoman

Kitty: I really appreciate you providing this link.  As more people are dxd every day, and the costs to treat cancer keep going up as a result, clearly the insurance companies are going to look for advantageous ways to "manage" our care.  I think every little piece of news regarding insurance companies we need to take notice of as they are collective caveats.   I just hope, I so sincerely hope that all the cancer folks do the 5 million man march if they try to pull any tricks.  There needs to be solidarity.  I am happy for signon.org where we can all go to sign any petition regarding legislation designed to minimize us and where we can also organize to march.  There will need to be a referendum because they are indeed looking to cut their costs and for lack of better words, screw cancer patients.  Therein lies the issue with a capitalistic driven healthcare system.

Don't forget, .Romney is convinced his dog loved being stuffed in that cage, tied to the roof of the car, for a 3 hour drive!  That same dog math looks like this:  they love having no healthcare and losing their homes to medical bills! Those cancer patients love this!!  Sorry to get political, all, but the times, they are a gettin' scarier! 

otter

Well. 

Methinks we've just gone over the cliff.

otter

KittyKitty

Lizzymack: yes.

When insurance clearly spells out what they see as the future for healthcare, in an industry journal, and the way they want to handle OUR healthcare, I am certainly going to take notice of that, and not stick my head in the sand and say, "but no, it is not like that now, so that is an alarmist article." That kind of reasoning I do not get. It is very easy to look at articles in insurance industry and ASCO publications, and to see the plan that they are working towards, it is no secret.

As Otter said, and what struck me as very odd about the article in the first place, was the attempt to put people in broad groups, "Cancer Pathways", when the trend in science is clearly the opposite direction.

Also, as anyone who has dealt with an insurance company knows, more choice in the doctors hands means more personal options in treatments, it is not like these insurance companies are on the leading edge of science and are looking to educate doctors and help patients with their concept of"Cancer Pathways". Anyone who thinks that their oncologist is going to learn something and be educated and guided by having an insurance company set up a "Cancer Pathway" needs to have a better understanding of what is going on in the real world.

As regards the affordable care act, I do think that the cost control issues in cancer are being talked about because of the prospective new influx of people being taken in to insurance plans which the administration seems to think is the only way to get everyone covered. IDK. There seem to be a lot of people who still will not buy insurance, and who might end up owing debts to hospitals for emergency care, even if that act gets cleared by the Supreme Court, which is where it is now.

If the Supreme Court strikes the individual mandate, but leaves the rest of the law intact for insurance to deal with, that certainly will be interesting.

Mardibra

IMO, there is no way i want the government involved in my health care.  I will stick with what I have, thank you.

1WonderWoman

The very last thing any of us cancer patients should be coveting is a continuation of this

capitalistic healthcare. For the record, my relatives are from Ireland and Italy and there are numerous women on here from Canada. I don't hear any complaints about their "government" healthcare. Fearing the unknown is narrow at best especially when there are a plethora of examples highlighting success.

susan_02143

Mardibra,

Government is already totally involved in your health insurance. MA has the strongest coverage laws in the country, one of the reasons we pay such high rates. The Commonwealth mandates all kinds of coverage and every health insurance plan in this state must meet those minimum requirements.

As I recall from a previous thread, we have the same health insurance provider and to be honest, they have been terrific.

For others, MA is one of the few states in the nation where all but one of the health insurance providers are not-for-profit and where over 50% of our hospitals are also not-for-profit. I only wish everyone had that option... to be treated by non-profit providers.

btw, Mardibra, you may have the best screen name I have ever seen!

*susan* 

Mardibra

I have always felt that my crazy cancer cells have been having a big ole party in my bra. Hence, mardibra!



You are correct about MA involvement in my private healthcare. But, the thought of any more involvement, or national healthcare, scares the crap out of me. Government has a lousy track record of being able to handle anything well without massive red tape, fat cats taking some for themselves, and general disorganization. Yes, our healthcare is expensive. Is it a perfect system? Hell no. But I would rather government stay out of my pocket. Ask a Canadian how long it takes to get an MRI. Ask a Canadian how much they pay in taxes for that not so great healthcare. Ask a Canadian doctor where all of their R&D comes from....the US. Have not yet heard of one single person with a serious disease running to Canada for treatment. They all come here.



I feel bad picking on the poor Canadians! Same can be said for others too.



I'm just one of those people who prefers small government even if it means I have to pay more. However, I do admit that our ability to care for those without insurance is horrible. Again, not a perfect system.



So what's the answer? Beats me. But the devil I do know is better than the devil I don't.

Mardibra

P.s. I work with a bunch of Canadians and many of them have additional private health insurance on top of the national healthcare. Sad, huh?

1Athena1

Mardibra, you can ask Canadians and get answers right here on BCO. They feel sorry for us -  as they should. Read the following thread:

http://community.breastcancer.org/forum/55/topic/784471?page=1#idx_11

(Thread title, on the Canadian forum, is: "We are so lucky")

I am always amazed by the level of ignorance in our country about other people's health care systems. Also, the feds manage their insurance far more efficiently than the US private sector does, with lower administrative overhead.

The US healthcare system is the most expensive amongst industrialized nations as a percentage of GDP, covering the least percentage of its people and leading to NO BETTER HEALTH OUTCOMES.

But we are probably number ONE-A in the lies we allow our politicians to tell about all of this.

Anonymous

LIKE, LIKE, LIKE for all Athena's posts.

We know things are really out of whack - has anybody looked at the cost of One Neulasta injection lately?  The cost of Arimidex when it was "brand" only, compared to the generic price now.

rosemary-b

We should stick to facts and not what we think will happen

Mardibra

Athena - i knew this was going to get ugly. Don't call me ignorant because I don't agree with you. And, as I stated earlier, I have spoken to Canadians .....in person ! Also, I was born in Ireland so I understand their system as well. There are good and bad points to all approaches. But, the Bottom line for ME is I don't want the US government running MY healthcare. Specific to Obamas national healthcare 73% of Americans agree with me.



As for everyone else? Its their own choice.

1Athena1

The US government will not run your healthcare under the Affordable Care Act. Insurance companies will, by and large, continue to dictate it, although at least one will be covered if one isn't.

I have no problem with different points of view on this. I only have a problem with how our media has twisted the facts. And run push-polls designed to favor a specific outcome.

But Mardibra if you happen to have insurance right now - if it's employer provided insurance (whether through you directly or a DH), then NOTHING changes for you. The Affordable Care Act will have no effect on me either because I am already an employer-insured person. Reform is not for you and me, but for the 50 million of our countrymen who have no coverage. Surely we want something better for them?

I can say that I made my own cancer decisions. in my case, I think my insurer was prepared to go much further than I did. For example, I refused chemo, but my plan would have paid for it willingly. For my co-morbidity, I did seek help out of network because the very best in that field can afford to not take insurance. So I pay through the nose there. But I probably would in England too and perhaps in Canada as well. In countries with national health systems, you can still go privately if you wish and pay out of pocket.

Where does the 73 percent figure come from?

Mardibra

This conversation needs to end. We will never agree so we should end it now.



Enjoy your weekend!

1Athena1

BTW, I did not call you ignorant because you disagreed with me. The point is, people are entitled to their opinions - just not to their facts. It's ok if you prefer a privately run system - as long as you don't say it's because it's more efficient than a government one, because it isn't. That's all I was getting to. Small government? Fine. I can understand the ideological reasoning. But not for reasons of efficiency in this case.

Beesie

Ask a Canadian how long it takes to get an MRI.  When my surgeon scheduled me for an MRI after I was diagnosed with BC, it took about 10 days.  These days I get annual breast MRIs. Because they are non-critical, the waiting time will be longer. To ensure that I get my MRI on schedule, I ask my doctor to send in the requisition for the MRI a couple of months in advance of the date that I want. I always get word of the appointment within 2 weeks of the requisition being sent in and every year my MRI is scheduled during the exact same week, always within days of the one year anniversary of my previous MRI. So with a little planning, the system works just fine.  BTW, recently a friend with a new cancer diagnosis (not BC) required a CT scan; he had it within a week.  A number of friends and family members have had different cancer diagnoses and none have had to wait more than a week to 10 days for any of their scans. 

Ask a Canadian how much they pay in taxes for that not so great healthcare.  A couple of years ago we did a comparison here on the tax rates in Canada and the U.S..  We discovered that when you add together all the different taxes, there is virtually no difference in the amount of tax that Canadians and Americans pay.  That actually surprised me; I expected the Canadian rates to be considerably higher.  Frankly, even if I do have to pay an extra few percent, the medical care and peace of mind that I get is worth it. 

Ask a Canadian doctor where all of their R&D comes from.  Are you kidding me?  The hospital that I went to is ranked as one of the top 5 cancer research hospitals in the world.  Look at many of the recent announcements about breast cancer - as examples, in the past couple of weeks the report that BC is really 10 unique diseases and the discovery of a new blood test that appears to be 100% accurate in identifying the presence of BC - these discoveries come from Canadian hospitals and university labs. Please do not be so arrogant as to think that all research comes from the U.S.. It doesn't. 

Here's one you didn't mention.  "Ask a Canadian how much choice they have about their care". A lot, actually.  We can pick our own doctors, we can change doctors, we can go to other doctors for second opinions, etc..  And it's our doctors who decide on our treatment.  Insurance companies in the U.S. have guidelines on what they will and won't pay for, depending on the patient's condition. Similarly, the Canadian healthcare system has treatment guidelines and standards for when and which tests should be ordered, etc.. But unlike in the U.S., Canadian doctors don't have to send in paperwork to get approval for a test.  They just do it. And they will be paid for it.  Canadian doctors have full authority to make decisions on behalf of their patients and to deviate from the guidelines whenever they feel it's appropriate.  

Have not yet heard of one single person with a serious disease running to Canada for treatment. Actually, many people come to Canada for treatment.  Of course you wouldn't hear about it because you are in the U.S..  Something else to consider.... critical mass. The U.S. has 10 times the population and as a result, the U.S. has more hospitals and larger hospitals and more specialists.  So Americans don't need to come to Canada for treatment because pretty much everything is available somewhere in the U.S.. But people from other countries do come to Canada.

I work with a bunch of Canadians and many of them have additional private health insurance on top of the national healthcare. Sad, huh? No, it's not sad.  It's practical.  The Canadian healthcare system doesn't cover everything. That would be unrealistic and unaffordable.  So, as an example, standard vision care isn't covered. However those who have vision loss beyond normal levels do have their costs covered and anything related to eye disease is covered.  This means that when I get my vision checked, I have to pay (or I could have supplemental insurance to cover this cost). But there is no cost to me for any of the tests that I get to check for glaucoma (it runs in my family). Similarly, other than for certain groups (seniors, for example, who don't have to pay for drugs) the cost of medication is covered only when the patient receives the medication in the hospital.  However my province has a drug plan that I can apply for, should my drug costs ever exceed 4% of my income. At that point everything would be paid. Most companies offer supplemental insurance to cover things like vision care, dental costs, drug costs, etc. and some people who don't have company coverage choose to purchase supplemental insurance.  The cost for this type of coverage is pretty low, compared to what most Americans pay for their coverage - probably in the range of $75 to $150 a month, depending on the level of coverage that you want.  I don't have any supplemental insurance and I manage just fine.

The Canadian system is far from perfect - just like in the U.S., the Canadian healthcare system is starting to be strained as all the baby-boomers hit their 50s and 60s - but it works pretty well.  As much as Canadians love to complain about our healthcare system (and we do!), it's something that most Canadians are proud of and most would never want to give up. Having said that, I can't say what would happen in the U.S. if a single-payer universal health care system were to be implemented.  There's no way to know if a U.S. system would run similarly to how the Canadian system runs or if there would be more regulations, more restrictions, more paperwork.....

Sorry for taking this discussion off track, but nothing bugs me more than some of misperceptions and inaccuracies that I read about the Canadian healthcare system. 

1WonderWoman

Beesie: as always, I love your contributions and I so thank you from the bottom of my heart!  Thank you so very much for that post! 

lassie11

What Beesie said (much better than I was going to say it).

suzieq60

In Australia, we have Medicare and a pharamceutical benefits scheme - ie government funded public hopsitals and refunds for basic medical appts. We pay 1% of our taxable income in a levy to cover the costs. Higher income earners pay more if they do not have private insurance. Medicare also covers GP's and prescription medicines, so when I go to the GP it costs me nothing - although some doctors do not bulk bill and you have to pay a gap. My prescription for Aromasin is a reduced price of $34 compared to $180 - full price. The government also covered the cost of my herceptin treatment to the tune of $75,000, however they do not cover the cost of breast MRI's but did pay for brain MRI - go figure.

We have a private health insurance policy (we would probably be dead without it). That covers in-hospital charges (accomodation and theatre fees) and the chance to choose your surgeon and have treament at a private hospital. We have to pay the surgeon/doctor but both medicare (85% of the scheduled fee) and private health (15%) give a refund. The problem is that the scheduled fees are too low, so for instance my anaethetist charged $500 - the set fee was only $200, so I was out of pocket by a lot. My first treatment saw me over $5000 out of pocket in spite of having private insurance. However, it cost me absolutely nothing for my chemo treatment as my onc does not charge over the scheduled fee. Radiation is not covered by Private Health insurance but by Medicare. Once you have reached $1200 out of pocket a safety net kicks in and you get an extra refund, so the rads cost about $1300 - real price over $5000.

There is no way in hell I would go to a public hospital here for treatment - waiting lists are VERY long. One man we knew was diagnosed with bowel cancer and had to wait 3 months to have surgery. People are waiting for years to get surgery eg knee replacements.

Our private insurance also covers dental, acupuncture, physio, eye wear etc. Annual limits apply for these extras but not for hopsital treatment.

For the money we pay every fortnight (164) it is well worth it as we will never repay them for saving our lives - my DH had bowel cancer, then lung mets and I stopped counting what our private insurance had paid out when I reached $100,000.

Sorry for all the numbers, but our system is very complicated - you need a degree to understand what is covered by Private Insurance and what is covered by Medicare over here.

ETA - there is a lot of criticism of our public system - currently we have a whistle blower in our state who is revealing murder by some doctors. I hope if the US does go to a government funded system that the standard is higher than ours.

painterly

Great post Beesie.

I would just like to add that Michael Douglas' cancer was found in Canada after being given a clean bill of health in the U.S. by several doctors.

 http://www.ctv.ca/CTVNews/Entertainment/20110504/michael-douglas-canada-health-care-110504/

pip57

Beesie, as usual, said it well.  But we thank all the Americans who are the testing ground for the plethora of new drugs that come on the market.  There are perqs to being recipients of evidence based tx in Canada.  Just saying....

Caya

Just had to jump in, being another proud Canadian - our universal health care is UNIVERSAL - as in every Canadian citizen gets treatment - ask the 45 milliion+ US citizens who do not have coverage because they cannot afford it, how they would feel about universal "government run" health care?

No one in Canada is mortgaging their homes, or holding community fundraising events to raise money to pay for treatment.  Nobody is terrified of losing their job, or staying in a job they hate just because they are afraid to lose their medical coverage.  When you are diagnosed with an illness, such as cancer, the last thing you want to do and worry about is filling out lots of forms to insurance companies for your treatment - there is enough stress dealing with fighting the disease, never mind fighting with an insurance company.  It seems to me, from what I have read on these and other boards over the past 5 years since I was diagnosed, the US insurance companies are making the medical decisions on what treatments/tests etc.can be done.  Here, as Beesie said, the government has guidelines, but the doctors order the tests. I saw my onc. about a month ago because I was limping and had hip/leg pain - he sent me for a bone scan within an hour!! I got an MRI within a week!  Yes, sometimes we Canucks have to wait a bit longer to get certain tests, but never in a critical situation.  I think the American insurance companies are whipping up a lot of propoganda in the US, because they are fearful to lose their lucrative status.

And I can go to whatever doctor, hospital I want to - no HMO dictating where I go, who treats me. Yes, in order to see a specialist, I need a referral from my GP - so what?  I can go to ANY DOCTOR I want to.  As for the R & D etc. - of course there would be more coming from the States, as Beesie said, there is 10X the population of Canada.  And yes, many Americans and others come to some Canadian hospitals for treatment - I know, because I have been sitting in waiting rooms in some downtown Toronto hospitals speaking to such people.

 Is our system perfect? - of course not, but it is fair and equal and morally the right path,  IMHO. Do we pay high taxes to get it - yes, but it seems to me many people in the US are paying very high insurance premiums - and what if you have a "pre-existing condition?"  No problem of that here, you are covered from the moment you are born.

And FYI, Herceptin was approved for early stagers in many provinces over a year before it was approved in the US for early stagers.  Just sayin.