Health Insurance:

Coverage of Autologous Bone Marrow Transplantation for Breast Cancer

HEHS-96-83: Published: Apr 24, 1996. Publicly Released: May 28, 1996.

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Pursuant to a congressional request, GAO reviewed insurance coverage of autologous bone marrow transplantation (ABMT) for breast cancer, focusing on: (1) the factors insurers consider when deciding whether to cover treatment; (2) the effectiveness of the treatment; and (3) the consequences of the increased use and insurance coverage of the treatment while it is still in clinical trials.

GAO found that: (1) the use of ABMT has become widespread and many insurers cover ABMT; (2) sufficient data do not exist to establish that ABMT is more effective than traditional chemotherapy; (3) despite the lack of data, many insurers cover ABMT because the research results of its effectiveness are promising, its use is widespread, and they fear costly litigation battles with their customers; (4) as of June 1995, seven states had enacted a law that mandates insurance coverage for ABMT and seven other states have similar laws pending; (5) of the federally funded health insurance programs, Medicaid coverage for ABMT varies by state, Medicare does not cover ABMT for solid tumors such as breast cancer, the Civilian Health and Medical Program of the Uniformed Services covers ABMT through a demonstration project in which beneficiaries may receive the treatment by enrolling in a randomized clinical trial; and (6) the widespread use of ABMT prior to conclusive data about its effectiveness may jeopardize patients unresponsive to the treatment, raise health care costs, and deter participation in randomized clinical trials.

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