Oregon Health Plan – Medicaid, Rationing of Care for Patients with Cancer Changes in Eligibility Criteria over the years from 1994 to 2018

This article explains how the Oregon Health Plan rations care for patients with cancer.

Dr Kenneth Stevens

By Kenneth R. Stevens, Jr., MD 

April 15, 2018

The Oregon Health Plan (Medicaid) uses a Prioritized List of Health Services (Link) established by the state Health Services Commission in determining what diagnoses, conditions and treatments will be covered. The Oregon Health Plan (OHP) was established in 1994.

It is currently under the Oregon Health Authority (OHA).

The OHP Guidelines for patients with serious illness have changed over the years.

During its early years (1994 to about 2008-2009), one of its guidelines was: 

“It is the intent of the Commission to not cover diagnostic or curative care for the primary illness or care focused on active treatment of the primary illness which are intended to prolong life or alter disease progression for patients with a 5% chance of a 5 year survival.”

This was the criteria used to deny Barbara Wagner of Springfield, Oregon from receiving chemotherapy for her recurrent lung cancer.

Barbara Wagner’s story: 

Barbara Wagner of Springfield, Oregon, a 64-year old great-grandmother was diagnosed with lung cancer in about 2006. Her cancer was initially treated with chemotherapy and radiation, and she went into remission. In early May 2008, a CT scan revealed her cancer was back and her cancer physician prescribed Tarceva (brand name erlotinib) a pill taken once a day for the purpose of slowing the cancer growth and extending her life. Studies show the drug provides a 30% increased median survival for patients with advanced lung cancer. One-year-survival rate for patients who took Tarceva increased by more than 45% compared to patients who took a placebo. She was on the Oregon Health Plan (Medicaid) and was notified in May 2008 that the OHP would not cover the beneficial chemotherapy treatment, “but that it would cover palliative, or comfort care, including, if she chose, doctor-assisted suicide.”

She said she was devastated when she found that the Oregon Health Plan wouldn’t cover the cancer medication prescribed by her oncologist. “I think it’s messed up,” Wagner told the reporter, bursting into tears. (“A Gift of Treatment – When the Oregon Health Plan fails to cover a cancer drug, the drugmaker steps in” by Tim Christie, June 3, 2008, The Register-Guard Newspaper, Eugene, Oregon.) 

She was particularly upset because the letter of denial said that doctor-assisted suicide would be covered! “To say to someone, we’ll pay for you to die, but not pay for you to live, it’s cruel,” she said. “I get angry. Who do they think they are?”

Barbara Wagner

Having been given no help or hope from the State of Oregon, her oncologist appealed to Genentech, the company that markets Tarceva in the United States, to cover Wagner’s medication. On Monday, June 2, she got the call from Genentech that they would cover the drug for a year, at which time she could re-apply. She was expecting delivery of the drug on June 3. “It’s fantastic”, she said, “I can’t wait to start the medication.” Ultimately, the drug company demonstrated more concern about Barbara’ continued survival than did the state of Oregon.

Mrs. Wagner died a few months later.

The Oregon Health Plan later changed the guidelines for patients like Barbara Wagner.

The guidelines for the January 1, 2010 OHP Prioritized List (revised 7-21-10) states:

Guideline Note 12. Treatment Of Cancer With Little Or No Benefit Near The End Of Life.

All patients receiving end of life care, either with the intent to prolong survival or with the intent to palliate symptoms, should have/be engaged with palliative care providers (for example, have a palliative care consult or be enrolled in a palliative care program).

Treatment with intent to prolong survival is not a covered service for patients with any of the following:

• Median survival of less than 6 months with or without treatment, as supported by the best available published evidence. 
• Median survival with treatment of 6-12 months when the treatment is expected to improve median survival by less than 50%, as supported by the best available published evidence.
• Median survival with treatment of more than 12 months when the treatment is expected to improve median survival by less than 30%, as supported by the best available published evidence.
• Eastern Co-operative Oncology Group (ECOG) performance score of 3 or higher 

The Health Services Commission is reluctant to place a strict $/QALY (quality adjusted life-year) or $/LYS (life-year saved) requirement on end-of-life treatments, as such measurements are only approximations and cannot take into account all of the merits of an individual case. However, cost must be taken into consideration when considering treatment options near the end of life. For example, in no instance can it justified to spend $100,000 in public resources to increase an individual’s expected survival by three months when hundreds of thousands of Oregonians are without any form of health insurance.

Treatment with the goal to palliate is addressed in Statement of Intent 1, Palliative Care.

The most recent guideline 3-22-2018 states:

Guideline Note 12, Treatment Of Cancer With Little Or No Benefit 

Cancer is a complex group of diseases with treatments that vary depending on the specific subtype of cancer and the patient’s unique medical and social situation. Goals of appropriate cancer therapy can vary from intent to cure, disease burden reduction, disease stabilization and control of symptoms. Cancer care must always take place in the context of the patient’s support systems, overall heath, and core values. Patients should have access to appropriate peer-reviewed clinical trials of cancer therapies. A comprehensive multidisciplinary approach to treatment should be offered including palliative care services (see Statement Of Intent 1, Palliative Care).

Treatment with intent to prolong survival is not a covered service for patients who have progressive metastatic cancer with:

A) Severe co-morbidities unrelated to the cancer that result in significant impairment in two or more major organ systems which would affect efficacy and/or toxicity of therapy; OR
B) A continued decline in spite of best available therapy with a non reversible Karnofsky Performance Status or Palliative Performance score of 3 or higher which are not due to a pre-existing disability.

Treatment with intent to relieve symptoms or improve quality of life are covered as defined in Statement Of Intent 1, Palliative Care:

Examples include: 

A) Single-dose radiation therapy for painful bone metastases with the intent to relieve pain and improve quality of life.

B) Surgical decompression for malignant bowel obstruction.

C) Medication therapy such as chemotherapy with low toxicity/low side effect agents with the goal to decrease pain from bulky disease or other identified complications. Cost of chemotherapy and alternative medication(s) should be considered.

To quality for treatment coverage, the cancer patient must have a documented discussion about treatment goals, treatment prognosis and the side effects, and knowledge of the realistic expectations of treatment efficacy. This discussion may take place with the patient’s oncologist, primary care provider, or other health care provider, but preferably in a collaborative interdisciplinary care coordination discussion. Treatment must be provided via evidence-driven pathways (such as NCCN, ASCO, ASH, SBMT, or NIH Guidelines) when available.