Should Insurers Pay for Bone Marrow Transplants to Treat Breast Cancer?

By Ronald L. Scott
rscott@central.uh.edu

Aetna/US Healthcare has announced it will no longer pay for high dose chemotherapy with bone marrow or stem cell transplant (HDC/BMT) for the treatment of breast cancer, because clinical trials have thus far failed to establish that the high cost procedure is any better than standard chemotherapy. Arguments about the efficacy of HDC/BMT for breast cancer and other solid tumors have been contentious for at least the last decade. Aetna will continue to cover bone marrow transplants for breast cancer if conducted under the auspices of a clinical trial.

When HDC/BMT was first introduced, coverage was often denied for the therapy on the grounds that it was experimental. HDC/BMT was and is a very expensive treatment, costing in excess of $100,000. Most managed care plans and insurance policies do not cover treatment that is "experimental" or "investigational." However, virtually every treatment could be labeled experimental when first introduced, so the issue is really the standards that must be satisfied for a treatment to be accepted. If a physician believes his or her patient needs a treatment that the health care plan has denied as experimental, the plan must typically be convinced that the treatment is recommended by experts in the field, that the patient is in a class of patients shown to have benefited from the treatment, and that the treatment will benefit the patient--not just further scientific research.

Health plans usually offer participants "medically necessary" care. Historically, they have not subsidized or sponsored research or experimentation. In early cases, the courts were split on whether an insurer acted properly in denying coverage for the use of HDC/BMT for the treatment of breast cancer pursuant to an exclusion for experimental procedures. A woman denied coverage might have recourse to appeal the denial, depending on state and federal (ERISA) law. For example, Texas requires that any denial of treatment based on medical necessity be appealable to an independent review organization that has the power to order a health plan to provide the requested treatment.

In the case of HDC/BMT for breast cancer, many insurers agreed to pay for the therapy during the 1990’s even before efficacy was proven, after a number of lawsuits resulted in high damage awards against HMOs that refused to cover HDC/BMT. A few states passed laws requiring insurers to cover HDC/BMT for breast cancer. Aetna now says that the science is clear, and the therapy simply does not prolong life. Only one study concluded that HDC/BMT prolonged the life of women with advanced breast cancer, and that study has been discredited since the researcher now admits that he falsified data.

Aetna’s decision points up a common difficulty faced by courts and legislatures in mandating or otherwise encouraging insurance coverage for a particular medical therapy, i.e., medical science is not static. By the time courts and legislatures have intervened, the science may have changed. Some health plans have said they will continue to pay for the controversial therapy (even outside of a clinical trial) where the physician and patient feel it is appropriate. Aetna’s stance is better public policy. Health plans should be applauded for covering promising "experimental" therapies. However, with limited resources, it simply makes no sense for health plans to continue to pay for expensive therapies that fail to deliver on the promise.

02/23/00