Mass. effort to mandate biomarker coverage to help cancer treatment may encounter resistance
Photo | Courtesy | Akoya Biosciences
An Akoya Biosciences instrument for studying biomarkers in human tissue
A new bill aims to broaden access to a medical advancement that allows for more targeted and precise cancer treatment, but the legislation could encounter opposition from the insurance industry, which opposes coverage mandates.
Biomarker testing looks for information from cancer patients' genes and proteins to identify which treatment would be most effective for a patient's specific diagnosis and conditions.
"By testing certain patients for certain markers ... doctors are actually able to prescribe targeted treatment and match patients with the treatment that's most likely to be most effective for their individual cancer, and it also means that some patients can avoid broader systemic treatments like chemo and radiation, and instead use precision treatments, and those treatments often come with fewer side effects and better survival outcomes," Cori Chandler, state and local campaigns manager at the American Cancer Society Cancer Action Network, said at a legislative briefing on Wednesday.
The legislation (S 689 / H 1074), introduced by Sen. Susan Moran of Falmouth and Rep. Meghan Kilcoyne of Clinton, would require state-regulated insurance plans to cover comprehensive biomarker testing when supported by medical evidence of a need.
"What's important is that even though it's about medicine and health, it's something that is so logical. It really promotes saving time for folks who may not have that much time with serious illness, so getting the most effective treatment to as many people as possible as soon as possible," Moran said.
About 40 percent of commercial insurance plans in Massachusetts provide biomarker coverage that is more restrictive than the recommended National Comprehensive Cancer Network guidelines, Chandler said. Nationally, 66 percent of oncology providers reported that insurance coverage is a "significant or moderate barrier" to appropriate biomarker testing for their patients.
An actuarial analysis of the bill found that impacts on insurance premiums would be 14 to 51 cents per member, per month in the private market, and 5 to 9 cents per member, per month in the Medicaid market, Chandler said. These comprehensive biomarker panels could cost insurance plans an average of $1,000, she said, but the cost would be much higher for an uninsured individual payer.
The bill would apply to state-regulated insurance plans, which include small employer and individual insurance plans (including most plans that can be purchased through the Massachusetts Health Connector), Group Insurance Commission, which covers state employees, and MassHealth. It wouldn't apply to larger employer plans that are regulated at the federal level.
Moran, who is a breast cancer survivor, said getting the biomarker testing early in cancer care could save both patients and insurance companies valuable time and money if doctors can identify the best treatment first, without having to try other unsuccessful and possibly expensive treatment plans first.
"It's the uncertainty, it's the emotional toll, but it's also the waste of funds or ineffective treatments," she said. "I experienced this. When you're so vulnerable there are other complications that also cost, not only human costs, but money. So I think this is going to be one of those health care bills that not only moves our community forward in a healthy way in many respects, but it really saves money. And I think, I don't know, maybe we can tell the insurance companies their premiums are going to go down."
Massachusetts Association of Health Plans President and CEO Lora Pellegrini said her association opposes mandates that could add costs.
"We oppose all mandates that dictate the terms as these mandates add costs for consumers and employers," Pellegrini said. "As for this specific bill, we are reviewing it with our members. As with all mandate bills, we would expect that this bill would go through a mandate review at CHIA to determine the added costs and medical efficacy of such testing."
According to the American Cancer Society Cancer Action Network, 60 percent of oncology drugs launched in the past five years require or recommend biomarker testing prior to use.
Between 2000 and 2018, the amount of cancer clinical trials that involved biomarkers went from 15 percent to 55 percent, Chandler said, so if a patient has not had biomarker testing done they are not eligible for over half of the cancer clinical trials available.
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