Clinical trials: Promising decision from New Jersey

Some New Jersey insurers announce they'd pay for the routine care of patients in government-sponsored phase I-III cancer treatment trials.

Editorial. Jan. 31, 2000.

Clinical trials represent the last best hope for some patients today and are the essential step to finding cures that will help many patients in the future. Insurers and the health plans they offer should pay patient expenses for clinical trials. Mostly they don't.

So it was welcome news when some New Jersey insurers announced they'd pay for the routine care of patients in government-sponsored, phase I, II and III clinical trials for cancer treatments. The voluntary pledge came from the New Jersey Assn. of Health Plans, which includes the state's 10 largest insurers and whose members cover or administer plans for nearly 5 million people in that state.

By taking this position these companies honor what should be the fundamental commitment from insurer to insured. Individuals don't buy health insurance to collect fine-print exclusions. What they want, and have a reasonable right to expect, is that insurance will make proper resources available to them when needed. That's especially so for people facing a catastrophic illness. The AMA has long supported payment of patient charges for clinical trials, and that support isn't limited to cancer trials.

Patients are expected to benefit soon from this decision. Supporters hope 15% of New Jersey cancer patients are in clinical trials in a few years, as opposed to the 3% now, a figure that mirrors the national trial participation rate.

The insurers can also expect to get something of value, like treatments that are more efficient and save payers money. In any event, supporting the development of better treatments makes more sense than allowing new approaches to trickle into the practice of medicine untested and occasionally become de facto standards of care.

This important announcement comes on the heels of another striking turnabout by a health plan, the decision by UnitedHealth Group to dump most of its preauthorization bureaucracy for physician treatment decisions. There are some strong parallels between the two.

One is that, finally, some payers are responding to long-standing complaints by patients and physicians about how they, the payers, conduct their business. A key factor is that lawmakers are getting seriously into the fray on the side of patients. United was facing a determined movement toward patient rights legislation in Congress. New Jersey lawmakers had already held hearings, and some had begun saber-rattling for a law mandating that clinical trials be covered. They'd hardly be alone. Seven states have such laws, and four of them joined the roster just in the last year.

The second parallel is an intriguing admission for health plans to make. Both United and New Jersey insurance administrators say that their decision to dump these long-time positions aren't expected to raise their costs much if at all. United had its own experience to go on -- it spent $100 million a year and nearly always ended up agreeing with the doctors; the New Jersey insurers point to Mayo Clinic and Kaiser Permanente studies citing no significant increases in costs when patients take part in clinical trials.

In both cases only time will tell if the promise of these decisions will be fulfilled. In the wake of United's announcement, some physicians have complained about how United is handling its new policy (it turns out, coincidentally, that among United's strongest critics are physicians in New Jersey). Other health plans, meanwhile, have suggested that United was grandstanding.

In regard to the clinical trials coverage in New Jersey, one obvious problem is that it is limited to cancer. Another is that even though these insurers will include the payment provisions in the policies they offer, the self-insured plans they administer are not required to follow their lead. That suggests that patients should still check the fine print of their insurance contracts, even though the chances do seem better that they will be covered. But if there will be arguments over coverage matters such as these, it seems far better to have them be over the details of fundamentally correct policies rather than a health care system with just-say-no health plans on one side, the medical community trying to do its job on the other -- and patients trapped in between.