Fighting cancer is difficult enough without being blindsided by the Washington state Legislature. And when an insurance company and pharmaceutical company pile on, too, it’s enough to make a person sick.
Trust me, I know: The last three months, I have been trying to resolve an issue with all three entities concerning my health-care coverage, an issue created by this three-headed monster in the first place. My experiences in trying to resolve this issue is a microcosm of the current health-care crisis in our country, a crisis that is only going to increase nationwide if the Supreme Court overturns “Obamacare” and statewide if Washington enacts the proposed massive budget cuts to health and human services next year.
Diagnosed with cancer
In December 2006, I was diagnosed with a rare intestinal cancer called a gastro intestinal stromal tumor that metastasized to my liver. One tumor was surgically removed from my small intestine, and my doctors decided to treat the tumor in my liver with a chemotherapy pill called Gleevec.
I began taking Gleevec daily in January 2007, and the effects were immediate. CAT scans showed that the solid tumor in my liver turned into a fluid-filled cyst, with no sign of cancer anywhere else. I have been taking Gleevec every day since then and am currently in remission.
Thanks to the out-of-pocket insurance coverage I had purchased from LifeWise of Washington, a Premera Blue Cross plan, before my diagnosis, the Gleevec was covered 100 percent. Gleevec costs approximately $7,000 for 30 pills. Like a commodity such as oil, gold, or soybeans, the price of Gleevec changes every day.
Then, a year ago, the Washington state Legislature passed House Bill 1517 with very high bipartisan support. The intent of HB 1517 was to require that insurance companies cover oral chemotherapy medications comparably with the coverage for intravenous chemotherapy treatments.
Unfortunately, as a result of HB 1517, Premera changed my coverage starting Jan. 1, and my co-pay became more than $1,100 for 30 pills, an amount I was unable to pay. I found this out on Feb. 3, when I had seven pills left in the bottle.
Premera reported a profit of $119 million in 2011, with surpluses of $972 million.
Diagnosed with a loophole
I immediately called my oncologist, who had never heard of HB 1517. With the help of his assistant, I applied to the Novartis Oncology Patient Assistance Program by filling out a form and submitting a copy of my insurance card and proof of income. After about four weeks, Novartis accepted my application and sent me a free 30-day supply of Gleevec, which means I went three weeks without taking it. My oncologist said this would be OK for a short time.
To receive up to 12 months of Gleevec at no charge, Novartis instructed me to apply again by filling out another form. I did, and they sent me back another form that said they had received my application, and they determined I may be eligible for coverage from a nonprofit patient-assistance program called Patient Services Inc. If that program rejects me, I can reapply to Novartis, they wrote.
After filling out another form, I am cur rently waiting to hear back from Patient Services Inc. In the meantime, Novartis sent me another free, 30-day supply of Gleevec.
Meanwhile, I contacted the Washington State Office of the Insurance Commissioner, who told me that it sounded like Premera had found a loophole, and there was no point in filing a complaint because Premera was following the new law.
I also contacted my state representative, Jamie Pedersen, who e-mailed back that he was “quite surprised to hear that the law had been implemented in a direction that what had been so clearly the opposite of what had been intended.” So he contacted Rep. Laurie Jinkins, the prime sponsor of HB 1517, who e-mailed that she was “upset to learn that some individuals, covered by specific Primera Plans, were paying higher costs for their oral chemotherapy drugs.”
Jinkins worked with Premera and other government agencies and was recently informed that Premera will close the loophole starting Aug. 1 and resume covering 100 percent of the cost of Gleevec.
So I just need to rely on handouts for another three months.
As of press time, I once again have seven pills left in my bottle.
Novartis reported a net profit of $9.2 billion in 2011.
Who pays the price?
In an interview in the paperback edition of the Pulitzer Prize-winning book “Emperor of Maladies: A Biography of Cancer,” author Siddhartha Mukherjee explains the difference between the “cost” of a drug and the “price” of a drug: “A pill of Gleevec…can be synthesized for pennies. That is the real ‘cost.’ But the ‘price’ of Gleevec…is set by a series of social arrangements, by our willingness to or ability to pay this set ‘price’ and, of course, by the profit motives of the pharmaceutical industry.”
I have always felt lucky that my cancer and treatment have never really caused me much pain. I have always had a job, health insurance, great doctors and a support system of family and friends.
But what about the less-fortunate people who are debilitated by cancer or other serious illnesses, or are uninsured, or unemployed, or have families to support and mortgages to pay, or are all alone? What price do they pay when our health-care system fails them?
And what social arrangements allow this ridiculous system to continue and get worse? A society that is willing to treat some of its most vulnerable members this way is truly sick.
MATTHEW WILEMSKI, an award-winning columnist, lives in Wallingford.
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