Coverage for cancer biomarkers and the impact of climate change on health care costs.

April 21, 2023

Today, I’ll discuss evidence for insurance coverage of cancer biomarkers, which has been highlighted by a recent survey by a cancer advocacy organization. I’ll review information on what impact climate change could have on costs of employer-sponsored health insurance.

1.    Testing for cancer biomarkers is medically appropriate prior to treatment of certain malignancies

Cancercare.org, a charitable advocacy and service group, recently published a survey of 295 people who were treated for cancer and found that 29% who had cancer biomarker tests did not receive coverage for these. They note that one in ten respondents said that the biomarker test made them eligible for a clinical trial, and one in five said either that it saved them from unnecessary chemotherapy or radiation.

Source: Cancercare.org, April 12, 2023 LINK  (The press release does not include characteristics of respondents or how they were recruited).

Biomarkers are tests of cancer cells to determine what therapy is most likely to be effective at curing or slowing cancer. These tests are indicated for most people who are diagnosed with melanoma, breast cancer, colorectal cancer and non-small cell lung cancer, as well as those with other cancers who have spread widely. Many anticancer drugs are highly effective for cancers with certain genetic mutations but do little to help patients with cancers that lack those mutations.

Many of these biomarkers are “laboratory developed tests” that do not require approval from the Food and Drug Administration, and there is often not a specific billing code for each test. Some are FDA approved as “companion diagnostic devices.”

These biomarkers are increasingly included in National Comprehensive Cancer Network (NCCN) guidelines, and researchers for the American Cancer Society found that coverage of oncology biomarkers was “widespread but not universal.” Some claims for these tests are subject to prior authorization, and some claims for these tests are denied.  Current legislation requires or regulates coverage in 6 states, and there are legislative proposals in 9 additional states. These requirements only apply to fully insured health plans that are state regulated, and almost two thirds of those who have employer-sponsored health insurance are in self-funded health plans, which are exempted from state regulation.

The oncology community recognizes that underuse of cancer biomarkers means that some patients don’t get the most optimal medical care, and could suffer unnecessary complications of therapy, or die earlier. Researchers have also found racial disparities in the use of biomarkers in a review of electronic medical records that included over 120,000 patients with three types of cancer from 2017-2020. They found substantial racial disparities in use of these valuable tests in lung cancer and colorectal cancer, but no significant difference in breast cancer.

Source: Bruno et al, JCO Precision Onc 2022 LINK

Implications for employers:

-        Employers can check with their carriers about coverage for cancer biomarkers

-        These tests are expensive and not indicated for all cases of cancer, so many carriers implement prior authorization with expert review to avoid waste

-        Oncology practice is increasingly specialized, and many members being treated by community oncologists will benefit from an expert medical opinion or a second opinion at a National Comprehensive Cancer Center.

2.    Global warming is likely to increase the cost of employer-sponsored health insurance, although our response could lower medical costs.

Saturday is the 53rd Earth Day, a good time to reflect on the impact of climate change on health, health care, and health care costs. 

It was in the nineties on much of the east coast last weekend, and there was so little snow in Boston this winter that our snowshoes never made it out of the basement. This dramatic change in temperatures will clearly have substantial impacts on health and health care. Here are some of the reasons why global warming is likely to lead to higher health care costs.

1. Mosquitoes that carry infections including Dengue Fever, Chikungunya, West Nile Virus and Malaria will increase their geographic range, and be active for more of the year further from the tropics.

2. Mild, short winters have meant more ticks, which spread diseases including Lyme Disease, Babesiosis, and Rocky Mountain Spotted Fever.

3. Hotter temperatures will mean more cases of overheating, and will restrict how long and what hours workers can safely spend outside in many geographies. 

4. Higher average temperatures dramatically increase the likelihood of extreme heat days, which were associated with over 1300 excess annual deaths in the US from 2008-2017.

5. Wildfires associated with increased temperatures cause an increase in air pollution, and researchers in Australia estimated that this could be causing over 50,000 excess deaths in the US. The most harmful particulates from wildfires, p2.5, causes an increase in cardiac as well as respiratory disease.

6. Milder temperatures are leading to more ragweed and other pollen sources that can worsen allergy symptoms.

7. Climate change is likely to cause economic upheaval, whether from geographic displacement or loss of jobs.  This will increase mental health needs.

8. Global pharmaceutical supply chains may be upended resulting in critical drug shortages due to weather events as they were during Hurricane Maria in 2017

Not all news is grim.  We know that moving away from fossil fuels and toward electrification (and renewables) has the capacity to substantially decrease air pollution, especially in urban areas.  This could decrease cardiac and respiratory disease. The transition to this alternative energy future requires large investments and can support good-paying jobs, and decreased financial stress is clearly associated with improved physical as well as mental health.  A warmer planet could mean fewer cold-related injuries.

Implications for employers:

-        Climate change is likely to increase overall health care costs, although work to mitigate global warming could help decrease risk.

-        Employers should continue to evaluate opportunities to improve access to mental health services

-        Company efforts to decrease carbon footprints can help decrease the adverse impacts of climate change, and demonstrate concern for employee wellbeing.

3.     Miscellaneous follow-ups

a.     The Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC)  announced this week that those over 65 or with immune compromise are eligible for a spring booster, although fell short of recommending it. Those under 65 without immune compromise who have not yet had the reformulated (bivalent) booster remain eligible to get a booster. Those with immune compromise could be offered additional vaccinations at their providers’ discretion, so employers should not put in place quantity limits that could prevent payment for more frequent vaccinations.

b.     Merck and Moderna announced that an mRNA based individualized cancer vaccine was effective at increasing melanoma survival times in a clinical trial. The pandemic turbocharged efforts to adopt mRNA technology in vaccinations, which is now paying off in positive results in cancer as well as infectious disease

c.     Buffalo Bills player Damar Hamlin, who suffered a cardiac arrest playing against the Cincinnati Bengals three months ago, has returned to practice with his team. Cardiac defibrillation saved his life, and in February I wrote about how automated external defibrillators (AEDs) in the workplace can prevent cardiac deaths.

Please also check out this article we published this week. 

My WTW colleague Elodie Olsen, FSA MAAA and I had an article in HR Executive discussing how employers can evaluate vendor claims of cost savings. The article is not paywalled.

Have a great weekend when it comes!

Jef