Bone marrow transplants - insurance coverage

Healthfacts, Sept, 1996

Insurance companies would appear to be on firm ground in rejecting reimburse- ment for an expensive, unproven treatment unless people receive it in the con- text of a clinical trial. But a new government report on autologous bone mar- row transplant (ABMT) shows that the insurance industry's decisions often are influenced by factors other than scientific proof.

Use of ABMT has become widespread in the last seven years, even though its effectiveness remains uncertain, according to a new report by the U.S. General Accounting Office. There is no definitive evidence that it is superior to standard chemotherapy for advanced breast cancer. Worse, many women may be risking the treatment's severe side effects to no benefit. The cost ranges from $80,000 to over $150,000.

ABMT involves the extraction and storage of bone marrow in order to protect it while the woman is treated with extremely high, toxic doses of chemotherapy. During the treatment period, she is hospitalized and kept in sterile isolation to protect against infection. Once the treatment is completed, her bone marrow is replanted. About 5% die of infection and complications associated with the procedure.

Though just one of several high-cost experimental treatments for which many people think their insurance companies should provide reimbursement, ABMT has generated the most controversy. In several high-profile cases, women have suc- cessfully sued their insurance companies over ABMT coverage. Now at least seven states require insurers to cover ABMT for breast cancer.

Some cancer specialists are alarmed by the trend because they believe insurance coverage should be restricted to participants receiving ABMT in the context of a clinical trial. In fact, the availability of insurance coverage for ABMT has led many women to refuse participation in a randomized clinical trial because this would give them a 50% chance of being randomly assigned to the non-ABMT treatment group. This, in turn, has delayed the availability of scientific evidence for ABMT's efficacy. (Several European trials are in progress that should prove whether ABMT is superior to high-dose chemotherapy.)

Report is Free

The new government report was commissioned by Senator Ron Wyden (D-Oregon) to determine how widespread ABMT coverage is and the reasons behind reimburse- ment. A survey of 12 large insurance companies revealed that their decision to pay for ABMT was not only based on preliminary evidence of efficacy, but also other factors like fear of litigation and adverse public relations.

For a copy of Health Insurance Coverage of Autologous Bone Marrow Transplanta- tion for Breast Cancer (GAO/HEHS-96-83), contact the U.S. General Accounting Office, P.O. Box 6015, Gaithersburg, MD 20884-6015. Orders may also be placed by phone (202) 512-6000 or fax (301) 258-4066. The first copy is free; addi- tional copies are $2 each.