The agency that runs the Medicare program decided in late March that it will pay for patients to receive an advanced new treatment for prostate cancer called Provenge.
The decision was cheered by patient groups. The pressure was intense as they demanded that the Centers for Medicare and Medicaid Services (CMS) pay for the pioneering vaccine that already had been approved by the Food and Drug Administration. Early signals indicated the agency might deny payment because the drug is expensive.
But Provenge is expensive because it is expensive to make. The drug is created individually using each patient’s own cells and costs $93,000 for the required three treatments.
Patients with advance-stage breast cancer, however, are not cheering.
In December, the Food and Drug Administration revoked its earlier approval for Avastin, a cutting-edge biologic drug used to treat breast cancer that also is expensive. The agency decided the medicine's potential side effects were too great compared to its benefits. Many are still wondering if cost was part of the consideration.
Genentech, Avastin's manufacturer, has appealed the ruling. But if the FDA decision stands, thousands of women who wanted and needed the medication won’t be able to get it.
Both decisions symbolize one of the most pressing problems with our health sector -- government controls too many medical decisions.
People over 65 have virtually no choice but to use Medicare for their primary health coverage. So if Medicare declines to pay for a drug, seniors are, for all intents and purposes, denied access to it. Many private plans follow Medicare’s lead.
The treatments Medicare covers are determined by government officials. There are private plans within Medicare, but they’re highly regulated and limited in the coverage they can provide.
Provenge and Avastin are just two examples of many in which government officials will be deciding what treatments will or will not be available to us. Many of these decisions will be under the radar for patients and doctors, never knowing that government officials may well determine whether or not a doctor can prescribe an important, but possibly costly, drug for them.