Medicare Coverage of Pricey Cancer Drugs Sparks ‘Rationing’ Debate

BY Jason Kane  July 5, 2011 at 3:27 PM EDT


Photo by Bloomberg via Getty Images.

As health care costs play an ever-increasing role in Washington’s budget drama, Medicare officials announced last week they will continue to pay for two extremely expensive cancer treatments despite lingering questions about their effectiveness.

At a cost of about $88,000 per year, the cancer-fighting Avastin will still be available to eligible senior citizens for breast cancer treatment. The same goes for Provenge, a new “therapeutic vaccine” that boosts the immune system to fight prostate cancer for about $93,000 per course.

Even the staunchest number-crunchers are hesitant to argue against effective cancer medications. But in this economic climate, the high costs and limited benefits of the two drugs make them a target for health care analysts on both sides of the health care debate. Given the circumstances, they wonder, can Medicare afford it?

An advisory committee to the FDA unanimously voted last week to rescind Avastin’s approval for breast cancer patients, citing recent studies that show it is ineffective at combating the disease. But because Avastin maintains its FDA blessing to fight other cancers — and because so many women swear it saved their lives — doctors can continue to prescribe it “off label” for breast cancer and Medicare will continue to fit the bill.

Also last week, the Center for Medicare & Medicaid Services announced its conclusion that Provenge “improves health outcomes for Medicare beneficiaries” and is “reasonable and necessary.” Only men with advanced prostate cancer that has spread throughout the body and does not respond to hormone therapy or radiation are eligible for the treatment.

Medicare’s coverage decision will greatly expand access to the drug, extending the lives of thousands of elderly men by an extra four or five months.

When CMS began studying whether to pay for the new Provenge treatment several months ago, critics of health care reform swiftly joined outcry from prostate cancer sufferers who accused the agency of “rationing care” based upon costs.

That argument echoes the criticism that care will be rationed even further in the years ahead after the establishment of the Independent Payment Advisory Board — a panel created by the health reform law to cut costs in the Medicare system.

Rep. Phil Gingrey, R-Ga., recently reignited the debate by saying that under the presidentially appointed IPAB, “a bunch of bureaucrats decide whether you get care, such as continuing on dialysis or cancer chemotherapy.”

“I guarantee you when you withdraw that, the patient is going to die,” he said. “It’s rationing.”

Neera Tanden, chief operating officer for the Center for American Progress, a liberal advocacy group, said Republicans have been too quick to vilify the administration’s attempts to find savings in the current Medicare model — including comparative effectiveness research for expensive drugs.

“When the White House offers up ideas for comparative effectiveness, it’s really just about funding research that would show if they work or if other drug are more effective. Republicans attack that as rationing,” said Tanden, a former member of the president’s health reform team. “I’m concerned that discourse makes CMS intimidated when it comes to these decisions — and that drives up premiums and costs for everyone in the private and public sector.”

It’s still unclear whether treatments like Avastin and Provenge might be targeted for cost-saving in the years ahead. But Joseph Antos, a scholar of health care and retirement policy at the American Enterprise Institute, a conservative think tank, said there is already overwhelming pressure on Medicare to pay for these drugs, and that won’t change.

“From the patient side, there is an awful lot of expectation that these drugs should be provided and that translates into political pressure,” he said. “It’s really hard to tell a doctor who firmly believes this could help someone that they can’t use the fancy stuff.”

They likely won’t have to do that, said Gail Wilensky, a senior fellow at the international health group Project HOPE. If political buzz words like “rationing” and “death panels” keep flying around the nation’s capital, Medicare is unlikely to discontinue coverage for cancer drugs — no matter how limited their effectiveness.

“Whether or not this is sensible outside of a trial environment is a question we should be discussing as a society,” Wilensky said. “If we’re going to pay for these medications that other countries don’t, it would be nice to have a more rational discussion about all of this.”