Patients may find themselves caught in the middle between their health insurance company and their oncologist when it comes to selecting the drugs used to treat their cancer. Why is this?
The American Cancer Society explains biologic drugs (derived from living organisms such as yeast, bacteria, or animal cells) and biosimilar drugs, which behave similarly to the original, patented (i.e., brand) drug. It is important to note that biosimilar drugs are not the same as generic drugs, which are exact chemical copies of the original, brand drug.
A brand drug that is first to market may generate a significant revenue stream for the pharmaceutical company as a return on investment for the cost of researching and developing the drug. In the case of a particular biosimilar drug, expedited clinical studies can demonstrate its safety and effectiveness for approval by the FDA. This means that as clinical studies support the use of biosimilar drugs, there is competition on price for drugs that have similar effects on the human body. As a result, the cost of treatment becomes a factor in the decision-making process for clinical care.
When health insurance companies see potential savings from a biosimilar drug, they may adjust their coverage accordingly. Some health insurance companies may change their decisions about which biosimilar drug will be covered under the plan on a quarterly basis.
But where does this leave the oncologist—and the patient? What if the patient is doing well on a different drug? Does the health insurance company take into account the patient’s history of response to a given drug? Not necessarily. In most cases, cost drives decision-making, and savings may not be passed on to the patient. The oncologist has to balance the decision of what drug to use against the health insurance company’s drug formulary. The big question remains: What if the patient’s response to the change in drugs negatively affects the clinical course?
In some cases, genetics is the reason why some patients respond better to certain drugs than others. We have seen this in the treatment of different types of breast cancer. We can’t predict with certainty how an individual patient will react to a particular drug, so we rely on both published clinical studies and clinical experience to determine which drug or drugs have the best chance of working with the fewest possible side effects.
Oncologists should not be forced by health insurance companies to play Russian roulette with their patients over coverage decisions for cancer drugs. It is physicians who learn both the risks and benefits of drug treatments, act in the best interest of their patients, and who should make the call on such complex decisions. The decision as to which drug is best for a given patient should stay in the hands of physicians responsible for the care of their patients, not be left to the caprice of health insurance companies.
Paul Pender practiced clinical ophthalmology for 38 years, specializing in the medical and surgical treatment of eye diseases. He completed his residency at the world-renowned Wills Eye Hospital. His honors include a lecture series in his name by the New England Ophthalmological Society and the Secretariat Award from the American Academy of Ophthalmology for his work on webinars for clinicians.
Pender is passionate about patient-centered care. He believes that the patient-physician relationship should serve as the fundamental building block for health care reform. He is an advisor to Vxtra Health, a company committed to collaborating with physicians to earn trust and to reduce health care costs. By limiting the drain on health benefits budgets by intermediaries (health insurance companies, pharmacy benefits managers, and hospital systems), Vxtra Health establishes a path toward a new model of care, based on price transparency and fiduciary responsibility, starting with self-insured middle market employers.
He writes on timely medical issues on his website, his KevinMD author’s page, and other popular social media. He is the author of Rebuilding Trust in Health Care: A Doctor’s Prescription for a Post-Pandemic America (2020) and the ebook Standing Up and Speaking Out for Patients and Doctors: First Steps Toward Focused Health Care Solutions (2023).
