Cancer treatment may not be covered by Medicare: a 1st (1 Viewer)

[Ockham]

This is about a therapy for Prostate cancer called Provenge.

Provenge, a vaccine to treat the recurrence of prostate cancer, has been approved by the Food and Drug Administration (FDA). The vaccine is made from a patient’s own blood cells with cancer cells and an immune boosting substance. A three dose course of the immunotherapy is estimated to cost $93,000. According to the company producing the vaccine, that equals $23,000 per added month of life.

Medicare usually covers the cost of FDA-approved anti-cancer therapies. However, the Centers for Medicare and Medicaid Services (CMS) is still reviewing whether it will cover Provenge, and at what rate.

The CMS statute states that Medicare must cover therapies that are reasonable and necessary, while the FDA is instructed to approve drugs that are safe and effective. Because of the conflicting Federal coverage and approval requirements, there are some non-FDA approved drugs (called off-label drugs) that are paid for by CMS. However, with respect to Provenge, it appears that CMS is arguing that while the treatment is safe and effective, it may not be reasonable and necessary. For the first time, an FDA approved anti-cancer therapy may not be covered by Medicare.

An update on Provenge and the FDA | Ovarian Cancer National Alliance
Who is the Ovarian Cancer National Alliance?

The bold above is my emphasis in the article.

The questions. So who makes the determination if the booster is "reasonable" and what is the definition of "necessary"?

Is the treatment or lack thereof determined at all by it's cost?

If a person dies and was denied this treatment, will the government allow legal restitution (law suit) in the courts and also allow payment to family members?


Granted, Medicare has not yet made a final determination and denied use yet. It's also unclear as to what is "reasonable" and "necessary" and who ultimately makes that determination and on what basis. However, we're now toying with the "death panel" as it applies to Medicare coverage. My friends 78 year old father just went through seed therapy and is cancer free. If the cancer re-occurs and it's deemed additional expenditures for things like Provenge are no longer necessary and he (God forbid) dies from prostate cancer - what are our options other than "end of life" counciling? If there are no alternatives, then are we not just peons / cattle waiting on the good graces of our ruling classes to take pity on us and give us the treatment?

Very unsettling... if it costs too much, maybe we can haggle for our lives a little. Or maybe bid on ebay.

 

[RightinNYC]

Not that I think this will happen anytime soon in America, but I would have no problem with the government saying that $23,000/month (or whatever they deem to be too much) is not cost-effective and will thus not be paid for by the government.

It's not possible to have a healthcare system where everything is paid for regardless of how expensive it is. That's something that neither side wants to admit.

 

[Slartibartfast]

Not that I think this will happen anytime soon in America, but I would have no problem with the government saying that $23,000/month (or whatever they deem to be too much) is not cost-effective and will thus not be paid for by the government.

It's not possible to have a healthcare system where everything is paid for regardless of how expensive it is. That's something that neither side wants to admit.

This demand is one of the biggest reasons our healthcare costs are skyrocketing.

 

[Ockham]

This demand is one of the biggest reasons our healthcare costs are skyrocketing.

It's a shame the reforms that were passed didn't address the financial aspects of healthcare, as those reforms were initially meant to.

 

[Slartibartfast]

It's a shame the reforms that were passed didn't address the financial aspects of healthcare, as those reforms were initially meant to.

I agree. The legislation got so watered down that its expensive but not really effective.