GOVERNMENT and LAW

Focus of Medicare legislation shifts to oral cancer drug coverage

With prospects for a full Medicare prescription benefit sinking, some national patient groups are pinning their hopes on legislation that would expand the coverage offered by the federal health insurance program to oral cancer medications.

The Access to Cancer Therapies Act, introduced in the Senate by Sens. Olympia Snowe (R, Maine) and John Rockefeller (D, W.Va.) and in the House by Deborah Pryce (R, Ohio), has received the support of national cancer organizations and lukewarm approval from some pharmacy organizations, which consider it a fallback position if complete Medicare drug coverage cannot be passed.

"Whether it's cancer drugs or something else, it's a great first step and a move in the right direction," said Crystal Wright, v.p. of communication for the National Association of Chain Drug Stores. "It seems that it could be a win/win for the consumer and the senior as well as for pharmacists, allowing them to interact more with that group of patients they perhaps have not been seeing. But obviously we would hope that lawmakers would go for the full push here."

The legislation in the House (H.R. 1624) and the Senate (S. 913) would enlarge Medicare coverage to include cancer medications such as Gleevec (imatinib mesylate, Novartis), tamoxifen, and thalidomide, which are marketed exclusively in oral dose formulations. Under current rules, which some groups consider inconsistent, the only oral cancer drugs that are paid for through Medicare Part B are those with IV equivalents, which have to be administered in a physician's office.

While oral drugs make up only about 5% of the total number available for treating cancer and its side effects, that figure is expected to rise to about 25% over the next few years as medications in the pipeline are approved. The push to cover oral cancer drugs is also gaining strength because they are among the most expensive therapies available, and thus difficult to afford for seniors on fixed incomes.

"Seniors comprise a significant portion of the cancer patient population," said Rep. Pryce, who is co-chair of the House Cancer Caucus, "and many of those seniors cannot afford to pay out of pocket for oral cancer drugs, which are the future of cancer therapy."

Some reservations are bound to be raised about the narrow focus of the proposed legislation. "It's hard to say that anyone's against paying for medications to treat cancer," said Susan Winckler, v.p. for policy and communications at the American Pharmaceutical Association. "But I think you'll have a lot of folks saying, 'Why won't you pay for medications to treat diabetes or pain management or MS?' I think there will be some challenges to the bill in that people will say, 'Why is it so narrow?' "

For pharmacy, another weakness in the bill is that it would reimburse only for the cost of the drugs and not for the value of pharmacists' services. Mary Jo Carden, a pharmacist and lawyer who is assistant director of government affairs at the American Society of Consultant Pharmacists, said monitoring the use of cancer drugs is "just as critical" whether they're being administered in a physician's office or dispensed by a pharmacy to be taken at home or delivered to a long-term care facility. In the case of a drug dispensed by a pharmacy, she said, it "means the physician isn't there to see the patient take it, and it's important to have pharmacist intervention.

"Certainly we would want to see these medications paid for," she added, "but we want to make sure they are paid appropriately and that the cost of the pharmacists' services and any special packaging needs a patient may have," such as unit-of-use dosages and compliance aids, are included in the payment.

Winckler agreed. From the pharmacist's perspective, she said, the expanded coverage for oral cancer drugs would be seen as "a good thing." But the lack of coverage for pharmacists' services means the bill is "not great."

Winckler said APhA looks for several things when it evaluates reimbursement legislation. "The first is that you provide coverage, not discounts. This meets that criterion," she said. "The second is that if you provide coverage, make sure [it] is for medication management services, so that consumers know how to use the products. That's not in this bill. That's a problem." Consumers could make the best use of covered medications "if they could partner with their pharmacist ... and that won't happen unless those services are paid for."

What are the chances of the legislation passing? "I certainly think there will be some debate about it," Winckler said. "It may be one of those pieces that is put through in the last few days of the Congressional session."

In another development related to Medicare reimbursement, the Centers for Medicare & Medicaid Services has issued a new policy stating that injectable drugs should be covered if Medicare beneficiaries self-administer them less than half of the time. The policy, to take effect Aug. 1, specifically states that Biogen's Avonex (interferon beta-1a) for multiple sclerosis is covered.

Bruce Buckley

The author is a New York-based pharmacy journalist.

Bruce Buckley. Focus of Medicare legislation shifts to oral cancer drug coverage.

Drug Topics

2002;11:42.