COVER
Grassroots
Medicare Jeopardizes Trust Over Cost of Lupron
by
Harry Pinchot
Nov. 24 1998. Today if your doctor orders or administers an FDA approved treatment, Medicare will pay 80% of the bill. Changes are taking place in California, Arizona, Nevada, Hawaii, & Oregon that have not been debated by our elected representatives or discussed publicly by Medicare at a national level. These are changes being made by local insurance company executives, hired to administer Medicare payments.
Two drugs, in a class known as LHRH agonists can be used to extend survival for men with advanced and in some cases with early prostate cancer. Lupron, the one selected 85% of the time by treating physicians for its effectiveness and painless administration, happens to cost more than Zoladex.
These drugs are selected and administered by the physician and are reimbursed by Medicare. However, with Lupron costing more than the Zoladex, the local Medicare payment administrator has decided he will only pay the price of the less expensive treatment, regardless of which drug the doctor and patient wish to use.
Under this rule change, the patient would be required to submit an application for a permit, allowing him to get the drug he and his physician believe works best for him. If the patient gets such a permit, he will be expected to pay the difference in price. The rationale for this policy change, in the opinion of the local Medicare administrator, is that both drugs appear to be similar in how they work despite the fact these drugs have never been compared in an FDA approved study and the method of administration is considerably different.
Medicare has a policy known as Least Costly Alternative (LCA) which applies to the choice of durable medical equipment. Equivalent products are to be selected on the basis of price only. This policy was designed to ensure that Medicare doesn't pay $20 for a bedpan when a similar item can be procured for $10. That is how the policy has been applied in the past and how Congress intended it to be used. Our local Medicare administrator is now trying to apply this policy to prostate cancer drugs and to deny payment for the more expensive drug on the basis of cost only.
Here's the problem in a nut shell. You and your physician believe the more expensive drug is medically necessary. You have been using the drug to control your disease and you have benefited from the fact that the drug is administered through a smaller needle in a less painful procedure. But this bean counter has decided it's still costing too much money, so you're out of luck. You have paid into the system. You and your doctor have found a treatment that is helping you stay alive and pain free, but it is deemed too expensive, so you will be forced to pay the difference between Lupron and the cheaper drug, Zoladex.
And here's another problem: The real Least Costly Alternative for treating prostate cancer is castration, so maybe your Administrator will decide (as some local administrators have hinted) to pay only for that. We must stop this attempt to limit treatment NOW.
Harry Pinchot is a patient advocate who has prostate cancer.
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