The problem of insurance gaps in cancer patients

Why are cancer organizations waiting until it starts to rain before they suggest buying an umbrella?

“Join my Medicare Advantage plan and get free membership to a local health club, free glasses and dental care.” This time of year, during Medicare Advantage Annual Enrollment period, the only TV commercials that annoy us more often are for lawyers who want to help us if we were injured at work or in a car accident.

As oncologists, we all recognize the benefit of teaching people to avoid behaviors that put their future health at risk. Prevention and early detection have had the largest impact of all of our efforts to reduce the mortality from cancer. ASCO and the American Cancer Society devote significant dollars and effort to disseminate this message. Despite these efforts, over 1.5 million Americans were diagnosed with cancer in 2010 and over one half million died.

While the stress associated with a cancer diagnosis and treatment is severe, in many cases patients and families are subjected to the additional stress of unexpected insurance gaps that leave them with unimaginable and unmanageable bills. In some instances, this problem may actually prevent patients from receiving optimal care. Yet, we as oncologists and our national organizations do little or nothing to help patients prevent this serious problem. Nowhere is this issue more apparent than in the growing Medicare Advantage plan arena. Dental care and vision care are wonderful, but how important are they if the plan you joined only covers 70% of the cost of your cancer care.

This is a relatively new problem seen increasingly as the popularity of Medicare Advantage grows. In the past, most of our Medicare patients, who purchased “Medigap” policies, had almost complete coverage (after annual deductible) for intravenous therapies covered under part B and delivered in oncologists’ offices. Although in recent years oral agents covered under part D have presented an acute issue when the patients reach the “donut hole,” IV therapies have been covered except in patients who have not purchased supplements.

Unfortunately, otherwise well informed people who would never take the risk of Medicare part B without a Medigap policy, are now moving toward Medicare managed care products unaware that they may be facing 20 to 30 percent coinsurance costs for expensive outpatient therapies including chemotherapy. But not all Advantage programs are equal and the best have much more comprehensive coverage for outpatient therapies. In addition the information about the coverage is available if you really want to find it, thanks to a great effort by Medicare to require full plan disclosure. So why do people make the decision to join a less comprehensive plan? Because Medicare Advantage plans market the immediate availability of wellness services (which are also important) that a member can use right now and don’t proactively point out the gaps that may exist should members be faced with a serious illness. Would you if you were trying to sell health insurance policies?

So who is responsible? No one is right now. For some reason, the cancer community approaches the solution to this problem differently than we address cancer. If we applied the same strategy we use for cancer prevention, we would have organized efforts to educate the public (Medicare beneficiaries and their families) about the risks of Medicare Advantage coverage gaps and how to recognize those gaps. By educating the buyer, and, hopefully, moving the market toward more comprehensive plans, we could help to increase the number of plans that offer appropriate coverage for outpatient treatment of cancer.

It’s time for ASCO and American Cancer Society to step up and take this issue on. Wouldn’t it be refreshing next November if the commercial promising free health club membership, dental and vision care were followed by a public service announcement about how to pick a plan that will give you real coverage for cancer treatment? Maybe they can crowd out some of the commercials for lawyers looking for automobile accident victims. That would be a public service in itself.

Richard Leff is Chief Medical Officer of Conisus.

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