WPA, the health insurer, has pledged to fund a legal challenge for any of its policyholders who are denied NHS care if they ‘top up’, having obtained a QC’s opinion that this policy is unlawful.
The need to make private provision for the unexpected costs of a life-threatening illness was underscored with more evidence of erratic gaps in NHS funding for cancer drugs.
Each year an estimated 280,000 men, women and children in the UK face up to the emotional and physical hardships of a cancer diagnosis.
For many, the strain of coping with their illness is compounded by the financial impact of an often-sudden diagnosis, including loss of income after stopping work and having to pay for ongoing hospital visits and prescriptions.
But research shows that a postcode lottery still determines how far they are pushed into the red if they need expensive treatments for rare conditions, or to halt their cancer’s advance.
Currently, state funding for cancer drugs in England and Wales is determined by the National Institute for Clinical Excellence (Nice), which bases its decisions on whether there is enough clinical benefit to justify the expense.
Patients can appeal against Nice decisions at the local level, under the ‘exceptional case’ provisions. But the chances of winning at this stage will often come down to where the patient lives.
A survey by the Rarer Cancers Forum (RCF) found ‘huge variations’ in the way Primary Care Trusts decide on ‘exceptional cases’, with some approving all requests and others denying all.
Those patients who are not fortunate enough to win an appeal – or who don’t live in Scotland where many more cancer drugs are state-funded – must then find tens of thousands of pounds, often at short notice, if they are not insured. Some have even cashed in their pensions to get treatments to keep them alive.
The RCF study found 5,000 patients were forced to demonstrate exceptionality in the past 20 months. Of this figure, 1,300 were rejected.
“Having cancer should not cost you your home, but as many as 45,000 people each year are struggling to keep a roof over their heads and 15,000 have lost their homes,” says Macmillan, the cancer support group.
The RCF survey came on the heels of an interim decision by Nice to reject funding for four drugs proven to help with advanced kidney cancer, including Avastin, Nexavar, Sutent and Temsirolimus.
In deciding whether these drugs were value for money, Nice took into account the length of time the drug could extend patients’ lives set against funding treatments for other patients.
Sutent costs about £3,000 for a six-week cycle, or £32,000 a year. So with the drug able to potentially extend the life of a severely ill renal cancer patient by up to six months, it was not deemed cost-effective for the public purse.
WPA's ‘My Cancer Drugs’ is the only PMI plan on the market to be ‘drugs only’ and was specifically designed to plug the NHS gap. It pays for cancer treatments licensed in the UK but not available on the NHS. The insurer has also just launched ‘NHS Health Top-Up’ which is a health plan covering items such as dentistry bills, but also allows members to add cancer drugs cover for about £4 a month on top of their core premium. These top-up plans are competitive but they do come with a benefits cap of £50,000 and exclusions for those with a history of cancer and those aged 65 or above.
Private medical insurance: News update: August 2008