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COURTING DISASTER

part 2 of 2
As much as their cases have become a rallying cry for women seeking payment for the controversial bone marrow transplant treatment, Barbara Tepe and Cynthia Snow could just as easily be held up as examples of why insurance companies ought not to pay. After all, both women received autologous bone marrow transplants--and are, or soon will be, dead.

"It may very well be that the promising preliminary response rates will translate into increased overall survival rates," says Dr. John Cova, who directs technology assessment for the Health Insurance Association of America in Washington, D.C. "But it may very well be that they don't."

If CU's Roy Jones has a philosophical doppelganger in the battle over insurance payments for bone marrow transplants, it is Cova, who is as passionate about the right of insurance companies to not pay for bone marrow transplants as Jones is about forcing them to do it.

"I know Dr. Jones," Cova says with not-at-all-disguised contempt. "I know him well. I know his tactics. And I will debate Dr. Jones anytime, anyplace, anywhere about the effectiveness of high-dose chemotherapy versus traditional treatments."

Cova does not dispute Jones's numbers. But he does take violent exception when Jones promotes bone marrow transplants as a proven treatment for cancer. A more accurate statement, Cova says, is that the procedure is "promising"--no more, no less. "If insurance companies now are paying for this," he says, "it's only because they have been forced into it by the courts."

This summer's congressional hearings, and the federal government's subsequent decision to cover the procedure for its employees, added fuel to Cova's fire. Public pressure and moist-eyed sentimentality have no place in medical science, he says.

"What Pat Schroeder did, and what any politician does when they mandate transplants, is to subvert the scientific process," he rages. "As a scientist, it's shaken me to the bone. These people have left the arena of biomedical research and entered the arena of biomedical politics."

As evidence of how public pressure has compromised science, Cova points to the process the medical community uses to prove to itself that a new treatment is working. These tests are called clinical trials.

Last year the National Cancer Institute began four such trials. To guarantee that the effectiveness of bone marrow transplants on breast cancer is measured accurately, the trials are "coin-flip," or randomized. That means half the women who enroll receive the transplant, and half receive traditional chemotherapy. That way researchers can determine whether high-dose chemotherapy/bone marrow transplants genuinely work better.

The NCI's trials are scheduled to be completed in two to three years. Recently, however, one of the tests had to be canceled. Physicians couldn't convince enough women to take the chance that they might be in the group that received traditional chemotherapy rather than the bone marrow transplant and high-dose chemo.

To people like John Cova, the cancellation is as worrisome to science as O.J. Simpson's trial is to justice. Simpson's lawyers claim the former football star's guilt or innocence cannot be determined by an impartial jury because so many people already have formed an opinion based on gossip. In the same way, Cova says the women eligible for the National Cancer Institute's clinical tests had heard too much misleading information from the Roy Joneses claiming that the treatment absolutely works better than standard chemo.

In fact, Cova points out that many women don't know that a bone marrow transplant can be significantly more dangerous than traditional chemotherapy. He says his numbers show that up to 15 percent of bone marrow transplant patients will die from the procedure, compared with less than 1 percent for traditional chemotherapy. (While Jones concedes that more women die from high-dose chemo/bone marrow transplants than with traditional cancer treatments, he says that the percentage doesn't even approach double digits.)

When public pressure outpaces science, insurance costs more for everyone who pays a premium, Cova says. "It's easier for Pat Schroeder to make insurers the fall guy than to explain to the public what's really going on. The end result of this is on you and me. We're financing clinical research with a form of hidden and regressive taxation--higher premiums for everyone."

(This, responds Jones, is "bullshit." Not only does the insurance industry have an obligation to pay for any treatment that is ethical and that seems promising, he says, but they do it all the time anyway. He points out that cardiologists regularly use anti-clotting drugs considered experimental. But insurers cover it because it costs far less than bone marrow transplants and usually is buried in hospital bills. By comparison, bone marrow transplants must be preapproved by insurance companies, making it simple to reject them.)

Although not all physicians are willing to admit it, some of the uncertainty over how well bone marrow transplants really work has been brought on by the cancer research community itself. High-dose chemotherapy/bone marrow transplants began appearing on the scientific radar screen more than a decade ago. Yet it has been only recently that NCI's definitive trials attempting to nail down the procedure's effectiveness have begun.

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