Ohio State doctors are working with lawmakers to remove roadblocks to immediate treatment for Stage IV cancer patients. “Very often, Stage IV cancer patients already have the greatest number of symptoms and side effects. Starting their treatment right away is vital, not only for the emergency of treating their cancers, but also for the nature and impact of these side effects,” says David Cohn, MD, the chief medical officer of the James Cancer Hospital and Solove Research Institute. “The sooner we can begin treatment, the quicker the side effects will be reduced and their quality of life and long-term outcomes will improve.” A proposed bill currently in committee and introduced by state Senators Bob Hackett (R – London) and Hearcel Craig (D – Columbus) would ensure immediate access for Stage IV cancer patients in Ohio to the treatment plans and drugs prescribed by their physicians. The bill would require health insurance providers to eliminate the “fail first” or “step” therapy procedures that require patients to start treatment with their insurers’ preferred and often generic alternative drugs prior to receiving financial coverage for the therapies prescribed by their doctors. A patient’s cancer advances to Stage IV when it spreads beyond its primary site to nearby tissue, lymph nodes and organs throughout the body. It is more difficult to treat than at earlier stages. “The way it currently works is that insurance providers have rules and algorithms about how drugs can be prescribed,” Cohn explains. “You must do step A and only then, if the patient doesn’t respond, can you move on to step B.” The problem with this system, Cohn says, is that cancer treatment has progressed tremendously over the past few decades. There are now more drugs and scanning and treatment options, and cancer care at the OSUCCC – James is tailored to each patient’s unique cancer and the genetic markers of their cancer cells. Doctors’ experience and expertise are often more nuanced and informed than algorithms, and studies have shown that tailored treatments can lead to better long-term outcomes and fewer side effects. “This fail first system puts someone between a physician’s recommendation and the treatment a patient receives,” says Cohn, who specializes in treating patients with gynecologic cancers. “For example, certain drugs may have more side effects, and I want to try and avoid compounding pre-existing side effects that my patient is experiencing before starting a treatment. If this treatment is more expensive than the one that has the undesired side effects, I’m told by the insurance provider I can’t prescribe that medication until the less expensive drug is shown not to work.” When conflicts arise, doctors have the option to engage in an appeals process with patients’ insurance providers. This process eats up a significant amount of time and doesn’t always end successfully. In a survey by the American Medical Association of 1,000 physicians, 91 percent reported that the prior authorization process led to delays in necessary care and had a significant or somewhat negative impact on patient outcomes. Physicians and their staffs spend an average of 14.9 hours per week on appeals and prior authorizations to gain access to recommended therapies or tests. The Stage IV bill would eliminate many of these issues by requiring insurance providers to provide immediate access for medicines that meet one of three criteria: Approval by the U.S. Food and Drug Administration (FDA) Inclusion in the National Comprehensive Cancer Network (NCCN) list for treatment Support by peer-reviewed medical literature as best practices for treating Stage IV cancer Approximately 20 percent of OSUCCC – James patients are diagnosed with Stage IV cancer. “We get referrals from all over Ohio and well beyond,” Cohn says. “Of the 20 percent with Stage IV cancer, the treatment of only a very small percentage ever get to the level of being scrutinized by the insurance providers. This bill is critically important to allow these patients access to the drugs or tests that are, in the judgement of their physicians, the right choices for them. The care of every single patient is so important to us.”