Together with State Sen. Bob Hackett (R-London) and State Sen. Hearcel Craig (D-Columbus), The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC – James) today announced new legislation that would ensure immediate access to treatment for stage IV cancer patients in Ohio.
Under this newly proposed bill, insurance providers in Ohio would be required to eliminate “fail first” provisions that require patients to first try an insurers’ preferred and often generic alternative drug prior to receiving financial coverage for the therapy prescribed by a treating physician.
Cancer is a complex series of diseases that requires tailored treatments that are often driven by the unique characteristics of a patient’s tumor. “Generic” alternatives often involve older, less effective treatment options with more side effects.
Studies show tailored treatments are resulting in better cancer control and fewer side effects for patients who qualify for newer, molecularly driven, targeted therapies. Approximately 20% of patients diagnosed at the OSUCCC – James have stage IV disease, meaning that their cancer has advanced beyond the primary organ site and into nearby tissues, lymph nodes, organs and other areas of the body.
“Patients with stage IV cancer simply don’t have time to waste, and ‘fail first’ provisions do a disservice to individuals facing this diagnosis by restricting access to newer targeted therapies as a first course of treatment for cancer and its associated conditions. The first oath in medicine is to do no harm and, as such, we should be able to make treatment recommendations for patients based on what drug science tells us is most likely to achieve cancer control for that specific patient versus what the patient’s insurance company is likely to cover,” says OSUCCC Director Raphael Pollock, MD, PhD, a surgical oncologist specializing in sarcoma at The James.
The stage IV cancer legislation follows precedents set in Texas, Georgia, Delaware, Connecticut, Illinois, Minnesota, Louisiana, Arkansas, Colorado, Maryland and North Dakota that mandated removal of “fail first” provisions that require patients to first try the preferred and often generic alternative drug prior to receiving coverage for their physician’s prescribed therapy.
This bill would allow patients with solid tumors immediate access to the treatment chosen by their physician for cancer and its associated conditions. Under this new legislation, insurance providers would be required to provide immediate access for medicines that meet one of three criteria:
Approved by the U.S. Food and Drug Administration (FDA) for treatment of cancer and associated conditions;
Included in the National Comprehensive Cancer Network (NCCN) drugs and biologics compendia for treatment of the disease;
Supported by peer-reviewed medical literature as best practice for the treatment of stage IV disease.
The bill does not apply to experimental clinical trials, which are managed through a separate process.
“The impact of this legislation on insurance premiums should be minimal because we are not asking health plans to cover a drug that they would not otherwise cover. We are asking the plans to remove the additional burden placed on stage IV cancer patients to fail on another drug first if they have been prescribed a different therapy that an oncologist believes gives them the best chance for survival,” says Sen. Hackett. “We must do what we can to help those individuals who are fighting for their lives and do what we can to best support them not create more painful obstacles.”
According to the most recent cancer surveillance data from the Ohio Department of Health, more than 72,000 cases of cancer were diagnosed in 2016, the majority of which were breast, lung/bronchus or colorectal. An estimated 45% of lung/bronchus cases were diagnosed in advanced stages. While most cancer mortality rates declined or remained stable in Ohio, deaths from liver and bile duct cancer—a less common disease often diagnosed in stage IV—rose by 24% in males during this same period.
“This legislation will help us remove barriers to treatment for patients and families already facing difficult diagnoses and tough physical, emotional and financial challenges,” said Craig. “We are hopeful that this bill will be considered quickly and is implemented by all insurance plans in the future, including Medicaid, Medicare and self-insured plans.”
The stage IV cancer bill is expected to be presented to the Ohio State Senate Health, Human Services and Medicaid Committee by early 2020. A recording of the press briefing to announce this bill can be viewed here.