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Out Of Network And Out Of Luck On Clinical Trials

If you find yourself in the unenviable position of shopping around for a clinical trial for a chance at treatment for a life-threatening illness, the federal law overhauling health care makes your life simpler in some ways.

Health insurers have to keep paying the costs of your routine care while you’re in the trial, something that not all have done in the past. A survey done 10 years ago found that 60 percent of people who didn’t participate in a clinical trial thought their insurance wouldn't pay.

Even today, nearly 20 percent of cancer patients are eligible for some sort of clinical study, but fewer than 5 percent enroll, according to the American Cancer Society's Cancer Action Network. "Even the perception that costs might not be covered is enough to prevent patients from considering it," Rebecca Kirch, the network's associate director of policy, says.

But there’s a loophole in the law. If the trial is conducted by a doctor or hospital outside your network, the new protections don't necessarily apply.

If someone belongs to a health maintenance organization, for example, out-of-network care isn’t generally covered. The law doesn’t require plans to pick up the tab for routine patient care in a trial outside the plan network unless out-of-network benefits are otherwise covered. "It’s a concern," says Nancy Davenport-Ennis, founder and CEO of the Patient Advocate Foundation.

One possible solution is for the patient’s doctor to administer the drug being tested, for example, and report back to the director of the clinical trial. “In many cases, it’s possible to do an on-site clinical trial, if a patient’s physicians are willing,” says Margie Griffin, a senior case manager at the Patient Advocate Foundation.

Copyright 2023 Kaiser Health News. To see more, visit Kaiser Health News.

Michelle Andrews