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Last Updated: Monday, 27 June, 2005, 10:35 GMT 11:35 UK
Who will pay up for effective drugs?
Matthew Hill
BBC West Health Correspondent

Barbara Clark
Barbara Clark has breast cancer
Breast cancer patient Barbara Clark planned to sell her house to pay for an expensive drug called Herceptin.

Her case has raised questions about what the private medical insurance industry is doing to adapt to rapidly changing medical advances.

The 49-year-old mother of two was recently diagnosed with a hormone-related form of breast cancer, known as HER2 positive breast cancer.

She has fought to have Herceptin - which has only been available on the NHS to women with advanced breast cancer.

Insurers must see that by giving the drug when diagnosis is made it may reduce their costs
Breast cancer specialist

Recently, three separate trials - two in the US and one in Europe - showed using Herceptin can help patients with this type of breast cancer at a much earlier stage than expected.

They all showed a halving of the of cancer coming back if Herceptin is taken in combination with a particular chemotherapy regime.

One in four newly-diagnosed UK breast cancer patients has HER2 positive cancer.

The cancer, which generally affects younger women, has been given worldwide publicity after it was reported that Kylie Minogue has also been affected.

So with the prospect of Herceptin not being licensed for at least another year, where does this leave women who are privileged to have health insurance?

Mixed picture

I contacted the major insurers - and the responses so far show a very mixed picture.

Those companies that say they will fund the drug for women who have just been diagnosed with HER 2 include Norwich Union, Taunton-based Western Provident Association, and Standard Life Healthcare.

Exeter Friendly Society is waiting for guidance from the National Institute for Health and Clinical Excellence before deciding its policy.

Axa-PPP and BUPA will only fund Herceptin for women with advanced breast cancer.

However, Robert Royce, head of policy for BUPA, said: "We were approached by Roche on 8 June and we are working up a cost model with them so we can understand what the impact will be financially if we approve this drug.

"We are also working out what the clinical guidelines for its use should be from the trial so far.

"We are taking this topic to a meeting on 14 July within BUPA and hope to decide then.

"We obviously have to take into account possible contra-indications that some people can develope, such a cardiac problems, so we are working out if you should also do cardiac monitoring.

"We are also looking at how long the drug should be used for."

Unusual set-ups

One breast cancer specialist, who preferred to remain anonymous, told me: "Most oncologists have been using the drug for certain patients who understood the potential long-term risks, even though we did not have the results - because anything that works so dramatically in secondary disease is most likely to be powerful if added in at time of diagnosis.

People are always complaining about the rising costs of their premiums but insurers will say this is the cost of new medical technology
Philip Blackburn

"It has only been patients who really insisted on having the drug that had a chance of getting it.

"We ended up with many unusual set ups, such as patients' employers paying for the drug.

"There is another problem with some insurers we have seen increasingly because the drug is so expensive and successful in keeping women with secondary breast cancer alive for so much longer.

"Consequently some insurers are quibbling about this being a chronic treatment for a chronic disease, and are therefore saying it is not covered by their policies.

"But insurers must see that by giving the drug when diagnosis is made it may reduce their costs, as the patient is far more likely to be cured with a much shorter and therefore cheaper course of treatment than using the drug for much longer when the disease is no longer curable.

"I have only seen one suitable private patient since the results came out in America and we are optimistic that she be funded.

Grey area

Philip Blackburn, health insurance analyst from Laing Buisson, said: "At the moment private medical insurance covers acute conditions. It does not cover chronic conditions.

"This is a very grey area as if acute treatment goes on for years it becomes chronic and there is some overlap.

"The insurer will stop paying when the acute condition disappears and the chronic phase appears.

"The private sector will have to develop to cover patients for treatments that the NHS does not cover.

"There will be a niche there for insurance to develop high cost treatment drugs.

"It's a question of can consumers afford such policies in advance.

"It is an advantage to have private medical insurance covering you for these types of drugs but companies have to weigh up the cost of these drugs.

"People are always complaining about the rising costs of their premiums but insurers will say this is the cost of new medical technology.

"You have to find a way of containing those costs without alienating your customers who cannot afford it."

"As waiting times for operations in the NHS fall, private insurers will have to find new ways of adding value.

"One obvious way is to set up policies to cover an area of expensive drugs not available on the NHS."

Woman sells home for cancer drugs
08 Jun 05 |  Somerset

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