The National Cancer Institute has proposed a partnership with HMOs and insurers under which they would agree to cover the medical costs of enrollees who participate in NCI clinical trials.
Robert E. Wittes, M.D., director of the NCI's Division of Cancer Treatment, Diagnosis and Centers, made the proposal public at the American Association of Health Plans' annual meeting last week in New Orleans.
Under the plan, which is being reviewed by the insurance industry, HMOs and insurers would pay for experimental care, which generally has been excluded from coverage. That would allow the insurance industry to avoid a number of problems, proponents say. Those problems include facing legislative mandates to cover experimental treatments, paying inflated bills to cover the costs of such procedures, and defending against lawsuits and bad publicity resulting from decisions not to pay for experimental care.
Proponents also say the plan would ensure the viability of national clinical trials, which are being undermined as more insurers and HMOs bow to public pressure to cover experimental treatments. That has shrunk enrollment in the NCI's clinical trials of autologous bone marrow transplant, or ABMT, to treat breast cancer. Breast cancer patients can receive ABMT without participating in the trials (June 17, p. 56).
Wittes said the NCI is talking with HMOs and insurers and hopes they will renegotiate contracts with employers to allow coverage in clinical trials.
Many HMOs and employers are "categorically opposed" to covering experimental treatments, he said. Others realize they already are paying for those treatments but don't want more financial exposure.
But the costs of treating critically ill patients in most clinical trials would likely not exceed the costs of standard care. If so, cost-sharing arrangements with the federal government might be worked out, Wittes said. Those patients also would be getting "state-of-the-art" care, he said.
The NCI's proposal includes streamlining the trials through less restrictive eligibility criteria, less elaborate data collection and eliminating all but essential tests, which would reduce medical costs, according to a draft of the proposal sent to the AAHP.
A lot of issues need to be resolved before a partnership can be established between HMOs and the NCI, said William T. McGivney, vice president of clinical coverage and policy at Aetna Health Plans. McGivney made his remarks at the AAHP conference. HMOs should participate in only high-priority trials that address the nation's most serious health problems, he said.
He agreed that HMOs "pay for a lot of the costs of clinical research both on a passive basis and on an unwitting basis" as providers bill for experimental care under other diagnostic codes.
Managed care has been "portrayed as the big bad wolf" threatening experimental programs, he said. But the trials being set up across the country by hospitals and physicians to compete with the national trials are "the threat to our nation's biomedical enterprise," he said.