‘Fail first’ no more: Pennsylvania moves to expand coverage of treatments for advanced cancers

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HARRISBURG — Patients in Pennsylvania facing the most serious stage of cancer will no longer be forced to try cheaper drugs before their insurance covers other, more expensive treatments.

The state House on Tuesday gave final approval to a bill that would abolish the heavily criticized “fail first” approach for stage IV cancer, which requires patients to show no improvement with cheaper, insurance-approved drugs before moving on to more innovative approaches.

The bill is now before Gov. Tom Wolf, who intends to sign it, according to his office.

The measure was sponsored by Rep. Kerry Benninghoff (R., Centre), who has experienced cancer up close several times, first as a hospital orderly helping ill patients decades ago, and then again as the Centre County coroner. His late mother was diagnosed with cancer about 40 years ago.

He was confronted with the disease again in 2008 when doctors discovered his 4-year-old daughter had a brain tumor. She died after two years of surgeries and radiation.

“You do your best as a parent. You teach them to look left and right, but then like a thief in the night, this happens,” Benninghoff, who chairs the House Cancer Caucus, said in an interview. “It’s still raw.”

The bill would require health insurance policies to cover drugs prescribed to patients with stage IV cancer — meaning it has spread to other organs or parts of the body — as long as they have been approved by the federal Food and Drug Administration for cancer treatment and are consistent with best practices.

“When you sit in a hospital for 2½ years, you get a lot of opportunities to talk to patients, families, and doctors,” Benninghoff said. “Physicians go to school to practice medicine and get people well — they don’t go to deal with legislative policies or insurance companies.”

Currently, oncologists shrink tumors and target cancerous blood cells with a cocktail of drugs, surgeries, or radiation treatments following protocols — schedules of when and how much of a medicine to administer — that are approved by a health insurance company’s reimbursement plan.

“Fail first,” also known as step therapy, can postpone access to potentially life-prolonging therapies, Elizabeth Franklin, executive director of the Washington-based Cancer Policy Institute at the Cancer Support Community, said in an email.

“These policies can be shortsighted,” Franklin said, adding, “They have the potential to cause significant harm as they may delay access to therapies that are the most appropriate and effective.”

This bill, Benninghoff said, changes the dynamic between physicians and health insurance companies.

“I think it is ridiculous when the insurer is trying to dictate medical decisions,” he said. “[The legislation] puts the patient and the doctor in charge. At stage IV, the cancer is aggressive. We want to give the patient the best chance — not make them go through weeks of medications that don’t address that person’s concerns at the time.”

A major Pennsylvania-based insurance company supports the bill, known as the Fair Access to Cancer Treatment Act, and hopes it will help rein in drug prices.

“[W]e are concerned about the increasing cost of prescription drugs which has a direct impact on our members’ access to affordable care,” Dr. Ginny Calega, vice president of medical affairs at Independence Blue Cross, said in a statement. “We believe this bill strikes an important balance between access, quality, and safety, including assurances that coverage follows clinical best practices.”

Rep. Pamela DeLissio (D., Philadelphia), a cancer survivor, voted no on the bill when it came before the House in 2019, because it does not cover the use of off-label drugs, medicines that have not been approved by the FDA for cancer treatment.

“In confounding situations, an off-label drug would be used,” DeLissio said by phone. “When it is stage IV, there are no more stages after that. If there was a possibility of a drug working, I would want to use it.”

Benninghoff said that he knows the scope of the bill is narrow but that sometimes compromise is the only way to move legislation forward.

“I don’t want to waste another day, week, month trying to fight for perfection, when we can help a lot of people,” he said. “Sometimes you have to take half a loaf instead of a whole loaf.”

Legislatures in Georgia, Illinois, and Maryland have passed similar legislation in recent years.

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