Kentucky mulls restricting Medicaid payments for three cancer drugs

goal is keeping costs down

bmusgrave@herald-leader.comMarch 28, 2011 

FRANKFORT — Kentucky health officials are considering restrictions on the number of cancer-fighting drugs Medicaid patients may receive without prior approval, a move designed to contain costs in the health care program for the poor and disabled.

The possibility of creating a non-preferred list of oral oncology drugs — pills that replace intravenous chemotherapy drugs — that Medicaid won't pay for without prior approval has raised questions from patient advocates and those who treat cancer patients.

Dr. Donald Miller, executive director of the James Graham Brown Cancer Center at the University of Louisville, said he understands the need to cut costs, but limiting cancer drugs may have unintended consequences.

Miller said cancer treatment plans differ greatly depending on the patient, the type of cancer and the stage of the cancer.

"We all have to be concerned about health care costs," Miller said. "We also are concerned that our patients get the very best treatment."

Cabinet for Health and Family Services Secretary Janie Miller will have the final say on the issue, although a committee of health care providers has recommended that she put three oral oncology drugs on Medicaid's non-preferred list.

The drugs in question are a relatively new form of therapy that can be taken orally. The drugs have proven effective in treating cancers and are more convenient for patients. However, the drugs can be expensive, said Donald Miller.

If the state approves the limitations, Kentucky will likely be the first in the country to do so, said James Sharp of the American Cancer Society.

Sharp said several other states have considered similar moves as Medicaid rolls ballooned during tough economic times.

"We don't want to do anything that would remotely restrict access to care," Sharp said. "We don't want anything to come in between a patient and a doctor's ability to choose what is the best treatment regimen for that patient."

The Medicaid Pharmacy and Therapeutics Advisory Committee, which is made up of doctors, pharmacists and other health care providers, voted March 17 to follow the recommendations of Magellan, a private contractor that administers claims for the Medicaid pharmacy program, to limit payment for three oncology drugs.

The committee evaluates drugs to determine their clinical effectiveness but does not consider costs.

A patient could still get the three drugs left off the preferred list if they are granted prior approval from Medicaid, said Dr. Dale Toney, the chairman of the committee.

Dr. Cora Veza, an Elizabethtown oncologist and member of the committee, said she did not believe Magellan's recommendations would limit the treatment of Medicaid cancer patients. Veza said the three drugs are not commonly prescribed oral oncology drugs.

"I believe that Medicaid is going to give me the drugs that I need," Veza said during the committee meeting.

But Sharp and others are worried some patients will need the three drugs.

"Why go through the hassle of giving this person a drug that they have to fail on," Sharp said. "You've lost a week or two of treatment."

Sharp said the American Cancer Society will be talking to the cabinet about its decision in coming weeks.

In general, limiting the use of some drugs to cut costs is not unusual. Many private insurers routinely make such decisions.

Gwenda Bond, a spokeswoman for the cabinet, said patients who are already receiving the three affected oral oncology drugs would not be removed from the drug if Janie Miller accepts the committee's recommendations.

She said Janie Miller will make a decision in the next month.

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