Forum Airs Issue of Who Should Pay for Patient Care in Cancer Clinical Trials

WASHINGTON--Caring for patients and conducting research in theage of managed care raises tough problems for all involved, saidPeter Quesenberry, MD, director, University of Massachusetts CancerCenter, Worcester. "How can we assure access to treatment,support research, and still be cost effective?"

A panel of oncologists and health plan representatives aired thoseissues at a forum jointly sponsored by the Leukemia Society ofAmerica, American Society for Blood and Marrow Transplantation(ASBMT), and University of Massachusetts Medical School.

"To me," Dr. Quesenberry said, "the most significantworry in the managed care arena is an intolerance for up frontcosts." A bone marrow transplant, he said, may cost a quartermillion dollars, but the long-term survival brings the cost peryear of extra life down to $10,000--a highly cost-effective rate.

Insurers say they will cover newer procedures, such as transplants,that meet accepted standards of care or are supported by evidenceof outcomes research. "When a treatment reaches NationalCancer Institute Level III trial, it's no longer considered investigational,and we would pay for it," said Wendy E.J. MacLeod, MD, FAAP,of Blue Cross/Blue Shield of North Carolina. "Our problemis with unsupervised use of investigational therapies."

"But what about new research?" countered Patrick Beatty,MD, of the University of Utah. "How do you get outcomes ifnothing's covered until proven? How do you make that first jump?"

Research support is not the primary concern of the managed careindustry, said Joel M. Kaufman, MD, medical director, Fallon CommunityHealth Plan, Worcester. "Employers pay for health insurance,not for research," he said, adding that a researcher whowants an insurer to cover a therapy of uncertain safety or efficacy"is asking a lot."

"It may be asking a lot, but it's the only thing to ask,"replied Joseph V. Simone, MD, physician-in-chief, Memorial Sloan-KetteringCancer Center. "How are you going to move the field forwardwithout trying something new?"

Several panelists suggested ways out of this seeming gridlockon who should pay for research, generally by bringing all playersto the table.

Mark S. Yerby, MD, MPH, a neurologist serving as a congressionalfellow on the staff of Oregon senator Mark Hatfield, said thatSen. Hatfield's proposed Clinical Research Enhancement Act wouldmandate that insurers cover the costs of care of patients whoare participating in trials of investigational treatments.

Dr. Quesenberry suggested that "standard of care" beredefined to mean "best available therapy," which wouldallow coverage for NCI phase I/II trials.

He envisions a national network to coordinate adequately constructed,sharply focused protocols, with large rapid recruitment rates.This network of researchers, he said, "could interface withthe managed care organizations and insurers so we could have thebest therapy options, do research, and evaluate outcomes."