Change of Address Changes Outlook for Brain Cancer Patient

Peter J. Neumann, ScD, of Tufts Medical Center in Boston and colleagues surveyed 1,379 oncologists to find out if cost of therapy was a consideration in their practices.

The survey, which was returned by 787 clinicians, found that 84% of oncologists said now say patients' out-of-pocket expenses influenced their treatment recommendations, but only 43% said they regularly discuss costs with their patients.

Just last week a commentary in the Journal of the American Medical Association noted that cost of cancer treatment has cancer care cost have jumped from $27 billion in 1990 to more than $90 billion in 2008.

Still, Lichter said, given Oertel's nine-year history of success with interferon, he thought the interferon should have been approved.

Spokespeople for Medicare and Cigna, which handles some Medicare claims in Wisconsin, said they could not comment on Oertel's case because of privacy rules.

In general, it is not unusual for companies that administer Medicare to reject a claim for a drug that is being used off-label (for a purpose it was not approved) or because it is not part of a plan's formulary, said Elizabeth Surgener, a spokeswoman for the Center for Medicare and Medicaid Services in Chicago.

Even when there is some support in published medical research for using a drug off-label, it still may be denied unless the drug is one of three compendia: American Hospital Formulary Service Drug Information, United States Pharmacopoeia Drug Information, or the DRUGDEX Information System, Cigna spokeswoman Lindsay Shearer, said in an email.

"Cigna and other Medicare Part D plan administrators are not permitted to cover excluded drugs," Shearer said.

Surgener said patients still have options, such as an appeal, when these types of claims are refused, although the process can be long. She said such drugs also might be covered if they are given in a hospital or by a doctor, as opposed to being taken by the patient at home.

However, unless the patient completes paperwork, their doctor can't file an appeal on their behalf, Shearer added.

Malkin said Oertel's case highlights several of the problems with health care in America, including a lack of portability of health insurance and a lack of respect for the treatment decisions made by doctors.

He said there is an utter random nature to the approval process in which people at private insurance companies as well as Medicare and Medicaid can make ill-informed life-or-death decisions.

With weakness on her right side from the growing tumor, Oertel moved from her apartment into an assisted living center earlier this month.

How she got to that point is complicated.

The pivotal event appears to have been a move from Fond du Lac County to Winnebago County in November 2007.

The change in residence triggered a review of her Social Security disability status, Oertel said. Oertel said Social Security personnel said they sent her a letter, but she said she never received it.

In any event, she went to a Walgreen's in Oshkosh to pick up her interferon and was told that her coverage had been canceled.

Oertel and her sister, Terrie, a registered nurse, said it took five months to reinstate her insurance coverage.

In the meantime, an FDA-approved drug, temozolomide (Temodar), that was not available when Oertel was diagnosed in 1998, now was available, Malkin said

Because the drug was proven and interferon was not, Malkin said he felt ethically compelled to use the approved drug.

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