Insurers spending millions on drugs with an eye on medical inflation
NHS patients seeking access to cancer drugs continue to face a postcode lottery, with the proportion of funding requests approved ranging from 0% to 100% across England, according to a Health Insurance investigation, carried out under the Freedom of Information Act.
We asked England’s 152 primary care trusts (PCTs) how many exceptional case funding requests for cancer drugs they received in 2009. These requests are made by patients or doctors seeking access to a treatment not routinely funded on the NHS. This includes cancer drugs not yet approved, or explicitly not recommended, by the National Institute for Health and Clinical Excellence (NICE), the independent body which makes decisions about what treatments the NHS should fund, based on their clinical and cost effectiveness.
Of the 122 PCTs who responded to our questions, a third (41) approved 50% or less of the requests for cancer drugs they received in 2009. However, 18 approved every request they received. The number of requests received by each PCT also varies enormously, from none to 112.
Professor Karol Sikora, medical director of CancerPartnersUK, who continues to work in the NHS, described the variation in the proportion of requests approved as “staggering”.
“[The response to requests] varies enormously but if you don’t ask you don’t get,” he said. “It’s very much the type of patient. The elderly and the poor on the whole don’t bother. I suspect that the appeals process is the preserve of white, middle-class, educated patients that can spend hours on the phone and fill in the blurb about why they are exceptional very well. This is patently unfair.”
David Stout, PCT network director at the NHS Confederation, which represents NHS organisations, said the research showed that the number of requests received by PCTs had reduced since two years ago when some PCTs received “hundreds and hundreds”.
When asked about private medical insurers’ responses to requests for cancer drug funding, Professor Sikora said he had been “so far mostly successful”.
“Most insurers are very reasonable and are quite right to query,” he said. “Most of their claims advisers seem knowledgeable, pleasant and easy to deal with, the antithesis of most PCT bureaucrats. The usual restriction – which is fair – is that I assess the patient after two months of therapy for response then make another request.”
Insurers contacted by Health Insurance stressed that they routinely fund drugs not approved for use on the NHS by NICE, but also outlined challenges not dissimilar to those faced by PCTs.
The three largest health insurers in the UK, Bupa, AXA PPP healthcare and Aviva UK Health will all fund drugs that have a licence from the European Medicines Agency, within the terms of that licence. This will include drugs not yet approved for use on the NHS.
“Bupa makes decisions regarding the funding of drugs in a similar way to NICE,” said Dr Katrina Herren, medical director at Bupa Health and Wellbeing. “However, Bupa’s decision time for new therapies is 48 hours. In addition, we look at clinical indication in isolation and do not carry out a health economics assessment. This means we usually fund drugs ahead of NICE and we fund a wide range of cancer chemotherapeutic agents”.