By Merrill Goozner, The Fiscal Times
This story comes from our partner 

Julie Grabow, an oncologist at the Fred Hutchinson Cancer Center in Seattle, recently prescribed an exciting new therapy for a 60-year-old woman with metastatic breast cancer.

Three-and-a-half years into her battle against the disease, the patient had already exhausted three different anti-estrogen therapies, each of which only put a temporary check on the spreading tumors.

The newly prescribed drug, Novartis’ Afinitor, is one of the recently approved targeted therapies that have generated a lot of excitement among cancer patients and oncologists in recent years.

Drugs that target just the cancer cells promise the same or better results as toxic chemotherapy, but with far fewer side effects.

There was a catch, though. Like many of the latest cancer drugs, Novartis is charging exorbitant amounts for the treatment – in this case, $10,000 per month.

That quickly put an end to that possibility for Grabow’s patient. Her monthly co-payment, even after her insurance company agreed to pay its share of the off-label use the drug (the Food and Drug Administration has only approved Afinitor for kidney and pancreatic cancer, not breast cancer), was $2,900.

“She can’t afford this, even though it’s potentially a less toxic and potentially equally effective regimen,” Grabow said. “Chemo will help her, and it’s a reasonable choice. But that choice is 100 percent driven by economics.”

Over the past year, official Washington and candidates on the campaign trail have locked horns over the best way to curb rising health insurance costs. The public has been bombarded with dueling slogans – Republicans vowing to fight the “death panels” and “rationing” of Obamacare while Democrats promise “guaranteed access” and “affordability” with the Affordable Care Act.

But an economic drama that neither side wants to confront is playing itself out in cancer wards and oncologists’ offices across the country.

Unaffordable new drugs, even when they’re covered by insurance, are being rationed by price as patients, doctors and hospital officials struggle with what is likely to be the most pressing problem for the nation’s health care system over the next decade: how to pay for the spectacular rise in the cost of cancer care, especially drugs and diagnostic tests.

“In the real world of private practice where most care is delivered, it would be a mistake to say rising costs haven’t affected care,” said Eric Nadler, a head, neck and lung cancer specialist at Baylor University Medical Center.

The growing cost of cancer care will impose its greatest burden on the nation’s Medicare system, since 55 percent of all cancers are diagnosed in individuals 65 or older.

A recent study by the National Cancer Institute projected the cost of treating the 29 most common cancers in men and women will rise 27 percent by 2020, even though incidence of the disease is going down due to successful public health campaigns like the war on smoking.

The study pointed out that its projections were based on 2006 Medicare claims data, which predated the development of most of the latest targeted therapies.

There’s no doubt that there will be many new therapies for cancer coming to market in the years ahead. The nation’s $150 billion public investment in understanding the biology of cancer – the science side of the War on Cancer launched by President Richard Nixon in 1971 – is beginning to bear fruit.

The pharmaceutical industry, which draws on that publicly funded science to develop drug candidates, now has 887 new cancer drugs in development, over 30 percent of its total portfolio of new drug candidates, according to the Pharmaceutical Research and Manufacturers of America, the industry trade group. That’s up from 646 or 26 percent of the total devoted to cancer in 2006.

The industry is pouring increased research and development resources in cancer therapeutics in hopes that it will replace the revenue being lost from the expiration of patents on blockbusters like Lipitor.

However, since there are fewer cancer patients than there are people with chronic conditions like elevated cholesterol, and many don’t live very long, the prices needed to support the industry’s current size and structure, and profits must be substantially higher.

“They’re trying to maximize profits given their incentives,” said Peter Neumann, director of the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center, which receives funding from the drug industry.

Possible solutions, he said, include letting Medicare set prices based on the medical value of adding extra months to life. That’s a variation on Great Britain’s cost-effectiveness model, which has been roundly condemned by most U.S. politicians and the press.

The other path is to turn to a bundled payment for every for every episode of cancer care and let the health care delivery organizations and private insurers sort it out. (Bundled payments account for all medical services associated with a given episode of care—doctors, nurses, technicians, etc.) That approach, in essence, would force the marketplace to execute the rationing.

“Bundled payment isn’t a panacea, but it does create incentives,” Neumann said. Some private insurers are experimenting with bundled payments for cancer care.

A quick review of the new cancer drugs approved by the Food and Drug Administration last year reveals how fast drug prices are rising.

Most of the older chemotherapy regimens for cancer, some of which have been around since the 1950s, are generic and relatively inexpensive.

But among the six new drugs approved in 2011, the cheapest – Johnson & Johnson’s Zytiga for advanced prostate cancer – cost $44,000 a year. The drug extended life by an average of less than 5 months to 16 months, according to a company spokesperson.

At the high end of the spectrum was Adcetris, a biotech product from Seattle Genetics that treats recurrences of Hodgkin’s lymphoma. A highly curable disease when initially treated in the 8,830 mostly middle-aged patients who get the disease every year, it is usually fatal if a drug-resistant strain emerges later in life.

Adcetris, the first new treatment to come along since 1977, kept the cancer in check for nearly 7 months in the single small trial that led to its quick FDA approval. It’s price tag: $216,000 for a full course of treatment.

Skin cancer specialists had a lot to cheer about in 2011 with two new therapies coming on the market for metastatic melanoma, which is fatal within one year for about 75 percent of the 10,000 people stricken each year.

But Roche/Genentech’s Zelboraf cost $61,400 a year and Bristol-Myers Squibb’s Yervoy, which nearly doubled the one-year survival rate from 25 percent to 46 percent, cost $120,000 for a four-month course of treatment.

“We price our medicines based on a number of factors including the value they deliver to patients and the scientific innovation they represent,” said Sarah Koenig, a spokeswoman for Bristol-Myers. “We have one of the most robust patient assistance programs for cancer patients in the industry.”

Most drug companies have patient assistance programs for poor or struggling patients, but many only come into play if patients are poor or families have exhausted their savings.

And since many of the latest therapies, like the older chemotherapies they are replacing or supplementing, extend life for brief periods of time, patients wind up weighing whether they want to deplete their children’s inheritances for a couple extra months of being very, very sick.

A study released at last June’s annual conference of the American Society of Clinical Oncology, which represents the nation’s 25,000 oncologists, revealed that patients with co-payments over $500 a month were four times more likely to refuse treatment than those whose co-payments were under $100 a month.

“The price of drugs can’t be set so outrageously high,” study author Lee Schwartzberg told Reuters. Schwartzberg is the chief medical officer at Acorn Research, which conducted the study.

“All stake holders have to get together and compromise to translate this great science into great patient care without breaking the bank.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

The talks will be held 7 p.m. to 8:30 p.m. every Thursday of the month.

What’s Stress Got to Do with It? — February 2

Dr. Bonnie McGregor is a behavioral medicine pioneer interested in how psychological factors affect the health of our bodies and our minds. Hear how stress influences our vulnerability to disease, and how stress management techniques can help you reduce your own disease risk.

Stem-cell Therapy: The Hope, the Hype and the Real Potential – February 9

Join Drs. Beverly Torok-Storb, Tony Blau, Phil Horner and Chuck Murry in a discussion of stem-cell research. Learn about the different types of stem cells, common misunderstandings about stem-cell work, clinical therapies being explored and what these researchers envision for the future.

Cancer and Infectious Diseases: Making a Global Impact – February 16

Did you know that nearly a quarter of cancers around the world are infection caused or related? Meet Dr. Corey Casper, the force behind the Hutchinson Center’s research on infection-related cancers in Uganda. By focusing efforts in a country with a higher disease burden, we hope to understand how chronic infections lead to cancer, including why this happens in some of us and not in others.

Influenza: A Study in Evolution – February 23

Soon personal genomic sequences will be cheaper than personal computers. But genomic sequences don’t come with instruction manuals, so revealing what they tell us about evolution and disease remains a challenge. Dr. Jesse Bloom will take us on a journey along the evolutionary path followed by one influenza gene over the last 40 years, and reveal the obstacles and forces that shape genetic change as we attempt to understand evolution at the molecular level.

When:

Thursdays
February 2-23
7-8:30 pm

 Where:

Fred Hutchinson Cancer Research Center
1100 Fairview Ave. N., Seattle
Thomas Building
Pelton Auditorium

To Register go HERE.

Each year, about 70,000 young people in the U.S. aged 15 to 39 years are diagnosed with cancer.

In the series, a group of teens and young adults from Children’s Adolescent Young Adult Oncology Program talk about their experiences with the disease – from treatments and hair loss, to dealing with school, friends and family.

Producers of the series hope that seeing other teens and young adults with cancer talk about their experiences will help other young patients struggling with the diagnosis of cancer cope.

“It is so important for these teens and young adults with cancer to know that there is a peer out there that understands what they are going through and that support is available,”  Dr. Rebecca Johnson, medical director of the Adolescent and Young Adult Oncology Program at Seattle Children’s Hospital.

The discussion group was facilitated by Teen Talking Circles, a nonprofit organization that offers teens “a safe place to tell their truth,” and trains adults to start Teen Talking Circles in their communities.

• To view the complete series go to:  ”Good Times and Bald Times” or click on individual episodes listed below.

• To learn more visit the website of the Children’s Adolescent Young Adult Oncology Program.

To learn more about the challenges facing teens and young adults with cancer read our series from the NCI Cancer Bulletin.

Series Episodes:

• Good Times and Bald Times – Meet the Circle
• Good Times and Bald Times – Family, Friends & Cancer
• Good Times and Bald Times – How Did it Feel?
• Good Times and Bald Times – Treatment and Medication
• Good Times and Bald Times – Eggs
• Good Times and Bald Times – Fertility Preservation
• Good Times and Bald Times – Food, Appetite & Cancer
• Good Times and Bald Times – Feeding Tubes
• Good Times and Bald Times – Losing Your Hair
• Good Times and Bald Times – PICC Lines, Hickman Lines & Ports, Oh My!
• Good Times and Bald Times – Dealing with School
• Good Times and Bald Times – What If

The new clinic will be located in the Providence Mill Creek Medical Building - 12800 Bothell Everett Hwy, Ste. 150, Everett, WA 98208.

The clinic will provide treatment for children, teens and young adults ages 0-21 needing non-emergency medical care in the evenings, over the weekends and during the holidays.

No appointments or referrals are necessary.

Providence Mill Creek Medical Building - 12800 Bothell Everett Hwy, Everett.

In general, the cost — and time waiting — are less at urgent care clinics than they are at emergency rooms.

Hours of operation for Urgent Care at Seattle Children’s Mill Creek Clinic will be the same as Children’s Urgent Care Clinics in Bellevue and Seattle:

• Monday through Friday from 5 p.m. to 10:30 p.m. and

• Saturday, Sunday and holidays from 11 a.m. to 8 p.m.

Children’s Urgent Care Clinics are not intended for serious or life-threatening emergencies, hospital officials cautioned, and if a child being seen at a Children’s Urgent Care Clinic has an emergent medical need, the patient will be transferred to an Emergency Room (ER).

To help parents decide whether to take a child to the ER or to urgent care, Seattle Children’s has prepared a quick guide:

The VA’s Aid and Attendance program, for instance, helps wartime veterans receive the care they need to stay in their homes or assist with long-term care expenses.

But many who are entitled to this benefit end up on Medicaid — which has significant implications for the veteran’s family members.

In 2003, the state of Washington began a pilot program to identify veterans who were falling through the cracks. In the years since, the program has served thousands of people who qualified for this assistance.

At the same time, it has helped relieve some of the fiscal pressure placed on the state’s Medicaid program by shifting these costs to the federal VA. Viewed as a win-win, the program has become a model for other states.

KHN asked two state officials invovled in the program’s operations to explain the basics of the Veterans Benefit Enhancement Project — how it came to be and why it is making a difference for both the state’s veterans and its budget.

Bill Allman, who developed and now manages the Washington State Health Care Authority’s program.Alex Deluao of the Washington State Department of Veterans Affairs

Bill Allman: How PARIS is helping veterans in need

About 10 years ago, I first heard about a federal databank called PARIS — the Public Assistance Reporting Information System. I

t was set up to allow both state and federal programs the opportunity to compare public assistance files, primarily to look for cheaters who were double-dipping by drawing the same kind of benefits from different government programs.

Astonishingly, a broader use of such a databank had gone unrealized until I started asking questions, particularly about the military and veteran program information available to the states.

With my background in medical assistance for the state of Washington, I was well aware of the fact that many poor veterans and their families were winding up on the rolls of Medicaid, never realizing that they might also be eligible for richer federal benefits.

For example, the VA will pay elderly/disabled veterans up to $23,396 per year and surviving spouses of veterans up to $12,691 per year.

And, the National Care Planning Council estimates that approximately 11.5 million seniors – about 33 percent of all people older than 65 – could qualify for pension or death pension benefits.

Here’s why: the PARIS data is keyed to an individual’s social security number, and includes information about state welfare and medical assistance billings, as well as that person’s eligibility for civil service benefits; Defense Department programs like CHAMPUS, a health plan for military dependents and surviving spouses; and the TRICARE managed care plan that serves many active duty military and retirees.

Therefore, armed with this databank, I had a way to uncover who was eligible but not receiving these veteran’s health care benefits.

In short, it was exactly what I had been looking for, because I was well aware that being on Medicaid was a disadvantage in another way.

If you know a veteran or family member in Washington State who needs our help, please let the VA know how we can reach them. 

• Call the Washington VA at 1-800-562-2308 or visit us online at www.dva.wa.gov. 
• To find another State’s Department of Veterans Affairs visit http://www.nasdva.net/.

When veterans died on Medicaid, their families usually lost their small estates because long-term-care-related Medicaid clients typically pay for a small portion of the health care they receive, but the programs do require the recovery of those costs if a client dies and leaves any kind of an estate behind.

Thus, the state, in this case Washington, has first claim or lien, through the “estate recovery process,” on a deceased veteran’s home, as well as other property and assets that went untouched while the individual was still alive.

But that’s not true for federal veteran benefits because those are provided in gratitude for the veterans’ service to country. As a Vietnam veteran myself, I was very conscious of what that difference might mean, and I had already begun to seek out ways to counter it.

PARIS was the answer. With a little effort, I found ways to use the federal databank to locate veterans on Medicaid and then help them transition to federal benefits. It had a good payoff for the state, too, which was dealing with budget crunches throughout the decade.

I took what I found to the head of my agency — Dennis Braddock, himself a helicopter pilot in the Vietnam War — and got the go-ahead to set up a pilot program in Clark County, which is located in southwestern corner of the state.

The initiative also has gotten the strong backing of Mike Gregoire, the husband of our current governor and a strong advocate for Washington state veterans.

We began our pilot in 2003, focusing at first on long-term care beneficiaries, most of them in nursing homes. From the very beginning, we worked in partnership with the Washington State Department of Veterans Affairs and other state social action programs.

Since then, we have become a model for many more states, with more than two dozen now beginning to evaluate the PARIS system and set up similar programs.

“Connecting veterans and their families to benefits they earned through their military service is simply the right thing to do,” John Lee, director of the Washington State Department of Veterans Affairs, told me. “This partnership allows us to reach out to veterans and families and let them know we’re here to help.”

For my part, I am still stunned to realize how many veterans did not realize they qualified for the federal benefits. In addition, they didn’t know that Medicaid benefits often aren’t free.

We’ve helped thousands of veterans in the eight years since we got our pilot up and going, and I think it’s fair to say we’ve saved millions of dollars for those veterans. Taxpayers, too, have benefited by some $30 million in cost avoidance as of the end of Fiscal Year 2011.

The program’s successes include not only moving vets onto federal VA health care  programs, but also enhancing some vets’ current benefits and lining up monthly cash payments and dependent benefits.

It’s amazing to me in retrospect that these loopholes exist in our health care system, letting people fall through the cracks when a little bit of forethought can prevent that.

I’m proud of our state for leading the way on this effort. The system we’ve pioneered is now in place to help future vets like those returning from Iraq and Afghanistan. I’m just one person and we’re just one state, but we made a big difference. That thought just knocks me down.

Bill Allman is the manager of the Washington State Health Care Authority Veterans Benefit Enhancement/PARIS Projects. Readers with questions about PARIS or related projects can contact him at William.Allman@hca.wa.gov.

Alex Deluao: Helping low-income veterans maintain the best possible quality of life

As Americans, we feel a sense of gratitude to those who raise their hands and defend our freedoms.

But sometimes, veterans miss out on the benefits they earned, something we often see when it comes to health care and long-term care.

You might be surprised that many people who served in the military either don’t consider themselves to be veterans or are too proud to ask for these benefits. This is especially true for older veterans whose military service is a distant memory, often decades old and sometimes purposefully forgotten.

For the most part, they probably got along just fine without anything from the government. But circumstances can change and sometimes extra help is necessary.

Take, for example, an older couple that recently received the assistance they needed from a veterans’ program.

The husband, a Korean War veteran, served his country, came home, and built a family and a career. He always had enough money saved away for the emergencies that life presented. But after suffering an injury, he knew he needed extra help.

His wife had been caring for him but she too was becoming frail, and he was worried that taking care of him was putting too big a burden on her.

This federal program can help wartime veterans remain at home or assist them in paying for long-term care. It’s available to lower-income veterans and their widows, who also qualify for VA pension benefits.

A large number of veterans across the country who qualify for this aid, however, somehow are slipping through the cracks. It leads to this very serious question: How do we connect veterans who are in need and who are eligible to this benefit?

Thanks to the creative thinking of employees at the Washington State Department of Social and Health Services and the Washington State Department of Veterans Affairs, we have found an answer.

In 2003, our agencies joined forces and started a pilot project to match federal VA data with the Public Assistance Reporting Information System.

PARIS, as it’s known, shows us who has applied for Medicaid benefits. When we match that information against the Federal VA’s data, we can identify eligible veterans or their widows, and help them apply for VA Pension and Aid and Attendance.

So far, we have helped connect more than 3,300 veterans or their widows to these programs and their benefits.

It’s one of those rare situations where everyone wins. Veterans receive monthly payments that can be used for in-home care or long-term care, and our state saves millions of dollars with fewer people using the Medicaid program.

Veterans also are able to utilize a benefit they earned through their military service, which, unlike Medicaid benefits, do not have to be re-paid.

There is nothing more satisfying than pioneering ways to help deserving people and we continue to be amazed at how much this partnership has done to help Washington’s veterans.

At WDVA, our goal is to help veterans and their families get connected with everything they earned, and we’re always looking for innovative ways to reach them.

If you know a veteran or family member in Washington State who needs our help, please let us know how we can reach them. Call us at 1-800-562-2308 or visit us online at www.dva.wa.gov. To find another State’s Department of Veterans Affairs visit http://www.nasdva.net/.

Alex Deluao is the manager of the Washington State Department of Veterans Affairs Olympia Service Center.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.