Statement of Principles on Medicaid Modifications 

Statement of Principles on Access to Cancer Clinical Trials

Statement of Principles on Oral / IV Chemotherapy Parity

Statement of Principles on Medicaid Modifications

Medicaid, which provides coverage to low-income families, children, older adults, and people with disabilities, is already one of the largest health insurance programs in the country will likely be expanded under health care reform to cover all individuals below 133% of the federal poverty level.  Jointly funded by state and federal government, Medicaid has become the largest source of general revenue spending on health services.  In an effort to meet the costs of Medicaid many states which are struggling financially have looked to program restructuring.  This restructuring may include cutting eligibility or service coverage, adding recipient cost sharing, reducing pharmacy benefits, or cutting or freezing provider payments all of which reduce access to health care for the countries neediest population.

With over fifty million beneficiaries, cuts to state Medicaid programs has the potential to significantly affect the United States patient population along with the family members involved.  Decreased access to care will create not only an unhealthy nation but an unhealthy economy as those with life-threatening illnesses cannot meet the necessary costs.  National Patient Advocate Foundation is critically concerned about cuts to state Medicaid programs.  We strongly support the expansion of state Medicaid programs included in health care reform legislation and will strive to protect patients' rights to gain access to, and reimbursement for, quality health care.  NPAF will monitor the expansion of Medicaid/SCHIP for access problems and for state maintenance of eligibility and seek legislative and regulatory solutions and corrections as needed.

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Statement of Principles on Access to Cancer Clinical Trials

National Patient Advocate Foundation lends its support for providing patients access to cancer clinical trials in an effort to progress cancer treatments and prolong the lives of many patients faced with this particular disease.  Currently there are fewer than 5% of adult cancer patients participating in clinical trials due in part to lack of insurance coverage.  While these trials are innovative and often offer the best and in some cases the only chance of survival, health plans may categorize the care as "experimental" and significantly limit or deny any type of coverage. 

With 10 million Americans living with cancer and another 1.5 million that will be diagnosed by the end of the year, progressive approaches must be utilized to ensure that patients are offered the best possible care.  By offering coverage of routine care costs such as doctor visits, hospital stays, clinical laboratory tests, and x-rays, health plans will increase access to trials for many patients across the United States therefore contributing to the future of medicine and offering patients the best therapeutic techniques available.  National Patient Advocate Foundation will work to pass state and/or legislation requiring health plans to pay the cost of routine medical care received as a participant in a clinical trial. 

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Statement of Principles on Oral / IV Chemotherapy Parity

Analysis of Legislation in 26 States Yield Universal Approach to Improve Implementation

Intravenously administered chemotherapy has been the standard cancer treatment since 1962, however, in the past five years sales of oral chemotherapy drugs have substantially risen.  Developed to improve patients' quality of life, provide a more convenient and less invasive method of therapy, and offer an alternative for patients who have failed to respond to other treatments, oral chemotherapy could potentially reduce resource utilization and health care system costs, improve drug safety, and enhance patient satisfaction.       

Evidence suggests oral chemotherapy is a more comfortable way to treat cancer with, in certain cases, more effectiveness and less adverse reactions than seen with I.V. chemotherapy and therefore viewed by patients to be the more favorable of the two treatment options.  However, many insurance plans have discriminated against oral chemotherapies as seen by non-coverage, limited quantities, or high co-pays as compared to intravenously administered chemotherapies which are generally covered in a much more comprehensive manner.  Financial factors rather than seeking options which yield best quality of life has therefore dominated patients' treatment choices up to this point. 

Eleven states (Colorado, Connecticut, District of Columbia, Hawaii, Indiana, Kansas, Iowa, Minnesota, New Hampshire, Oregon and Vermont) have passed legislation to require that coverage for oral chemotherapy treatments for cancer be provided on a basis no less favorable than intravenously or injected cancer medications.   Numerous other states have introduced similar legislation in 2009-2010.  National Patient Advocate Foundation (NPAF) has supported the intent of these bills which is to allow patients, when medically appropriate, to use oral rather than intravenous medications, when prescribed by their treating physician, since they are more easily administered and less disruptive to the patient's life.

Oregon, the first state to pass legislation, enacted the following language:

"A health benefit plan that provides coverage for cancer chemotherapy treatment must provide coverage for a prescribed, orally administered anticancer medication used to kill or slow the growth of cancerous cells on a basis no less favorable than intravenously administered or injected cancer medications that are covered as medical benefits. "

Other states have generally followed this model.  Concerns have been raised, however, that this language could lead to unintended consequences, specifically, that for some patients, anti-cancer oral medications could be moved from requiring a relatively low copay from the patient to a classification as a medical benefit or to a specialty tier classification requiring higher coinsurance rates for the patient.  To avoid such consequences, NPAF recommends that states, in adopting oral chemotherapy parity legislation, include the following language found in legislation introduced in Massachusetts:

"An increase in patient cost sharing for anticancer medications is not allowed to achieve compliance with this provision."

May 2010

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