‘Extremely unfair’ - the imbalance in health insurance cover for life-changing cancer drugs

Scores of patients with advanced cancer are losing out on access to the newest and most promising treatments because of their choice of private health insurer.

The plight of public patients forced to wait long periods for access to next-generation therapies is widely acknowledged but a separate access issue has developed over the past four years between customers of the three main health insurers.

In 2019, VHI broke ranks with its rivals by agreeing to fund wider access to cancer treatments for private patients. Irish Life Health and Laya Healthcare, which elected not to follow suit, generally wait for a drug to be approved on the public system before greenlighting it for customers.

[ Cancer doctors accuse insurers of denying patients access to new drugs ]

Since then, the number of new drugs, and the number of indications of these drugs for different cancers, has multiplied, leading to what oncologists say is a growing disparity in coverage between different providers.

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“Existing insurance customers and those considering taking out insurance do need to realise that there is a substantial imbalance in coverage for cancer between VHI and the other two companies,” says Prof John Crown.

This is reflected in the experiences of cancer patients who have talked to The Irish Times about the difficulty they have experienced accessing treatment through their insurer.

What is the benefit in having Irish Life or Laya insurance if you need treatment for metastatic cancer?

—  Prof Ray McDermott

Mary O’Loughlin, from Boolavogue, Co Wexford, is unable to access immunotherapy to treat her cancer because the drugs her consultant recommends are not funded by the HSE or her private health insurer.

Mary was diagnosed with a rare form of gastric cancer two years ago and has undergone extensive chemotherapy and surgery. Faced with a recurrence of the disease, her oncologist, Prof Ray McDermott, recommended the use of pembrolizumab or nivolizumab to treat it. It is “highly likely” her tumour will respond to this form of immunotherapy, he told The Irish Times.

“I was delighted, but then Irish Life said they don’t cover it,” Mary says. “The VHI will cover it, and the HSE don’t want to know about it for certain cancers.”

Prof McDermott asks: “What is the benefit in having Irish Life or Laya insurance if you need treatment for metastatic cancer, specifically a drug that has been shown to work and is recommended in all useful guidelines? In my view subscribers should know this when they choose their insurance plan and act accordingly.”

Mary is now back on chemotherapy, for which she travels from her home in Co Wexford to St Vincent’s hospital in Dublin every second week.

“It’s going very hard on me. Chemo is much harder than the immunotherapy – there’s awful fatigue, nausea, vomiting, hair loss and a feeling of being generally unwell,” she says. “At least I’m having it, but it would have been much better if I could have been given the immunotherapy. I’m wondering why we can’t have it in Ireland.”

She says she didn’t have the strength to take up the issue with her insurer but a family member helped her appeal the decision to refuse cover for pembrolizumab.

Irish Life declined the appeal, and also said it “cannot allow” an exception on compassionate grounds.

Ironically, Mary used to be with VHI but was switched by her broker to Irish Life 16 years ago; the broker receives a 3 per cent commission from Irish Life each year. She believes brokers should let clients know “what’s definitely not covered” before moving them to another health insurer.

While she could switch back to VHI next time she is renewing her policy, use of the immunotherapy would not be covered for the first two years under standard health insurance switching terms.

[ Nurses in 26 cancer treatment centres proving a valuable resource ]

Anita O’Connell believes the refusal of her health insurer, Irish Life, to fund a potentially life-changing treatment for her cancer is “extremely unfair” when it is available through another insurer, VHI.

After the 52-year-old woman was diagnosed with breast cancer in 2018, she was treated with aggressive chemo, surgery and radiotherapy. Her scans were clear for two years but then she experienced back and bone pain and required further treatment.

Prof Crown recommended a course of sacituzumab govitecan (Trodelvy), a new drug from Gilead Sciences that regulatory bodies in Europe and the US have approved for the treatment of secondary breast cancer. Clinical trials have shown it can slow progression of the disease by several months and extend a person’s life by about five months compared with traditional chemotherapy.

However, her insurer, Irish Life, refused to pay for the treatment, on the basis that it is not reimbursed by the HSE.

“I was extremely disappointed and very frustrated,” says Anita. “I felt my access to a life-changing drug is dependent on the randomness of the insurance company that my husband happens to be in, through his work.

“Time is not on my side. It is frustrating to think the people making these decisions probably do not have first-hand experience of what it’s like to have cancer and to have a time-bomb ticking over your head.”

She tried to switch insurance to VHI, which initially said it would fund the treatment but at the last moment told her it would apply a two-year wait period for eligibility because the treatment was considered an upgrade in cover. Staff apologised for the initial misinformation and suggested she might have a case with the insurance Ombudsman but she felt too stressed to take this on at a time when her disease is progressing.

All this tardiness while people’s lives are hanging by a thread

—  Anita O’Connell

For now, her hopes rest on a decision by the HSE to reimburse the drug, which would trigger coverage by Irish Life and its availability in the public system. The National Centre for Pharmacoeconomics, Ireland (NCPE) ran the rule over the cost-effectiveness of Trodelvy last March, and found it costs at least €82,000 per patient for a six-month course.

Its review concluded that the drug could be considered for reimbursement “if cost-effectiveness can be improved relative to existing treatments”.

This means the drug will be approved if HSE and Gilead can reach agreement on a reduced price. So far this has not happened.

Ireland is not the only country wrestling with these issues: the UK initially rejected Trodelvy then did a U-turn, while Dutch regulators are holding out for a 75 per cent reduction on the price quoted by the manufacturer.

“You wonder what all the red tape is for,” says Anita. “All this tardiness while people’s lives are hanging by a thread. This drug could change my life, and many others.

“I felt they didn’t try hard enough to help me. ‘Irish Life – we’re here to help.’ Well, they weren’t really there to help at all, to be quite honest with you.”

Responding to queries from The Irish Times, Irish Life says it funds treatments that have been approved by the NCPE, the National Cancer Control Programme (NCCP) or the Health Service Executive. The company last week announced an increase in premiums, for the second time this year.

Laya says it “accepts the guidance and direction” of the NCCP, the NCPE and the HSE, “in consultation with medical consultants involved in the treatment of patients”.

“There are times when we will approve drugs earlier than HSE-led approvals, where the treatments have been approved by the EMA and are supported by medical evidence.”

Acknowledging the frustration experienced by cancer patients, a spokeswoman says the company is “working hard to find ways to influence the speed at which funding decisions are made while upholding the clinical standards and regulatory guidance to ensure maximum patient safety”.

VHI says it is committed to ensuring members can avail of the best medically appropriate benefits “in a timely manner”.

“We will provide benefit for drugs in accordance with our membership rules and when it is medically necessary for these to be administered in a hospital setting.”