When hope starts to wane and standard treatments aren’t effective, many Americans with chronic or life-threatening illnesses look to experimental treatment options for a return to health. Clinical trials offer patients a way to try the newest treatment, while researchers collect information about its effectiveness. Researchers are cautious and trials are conducted with the safety and health of patients always in mind, but there are risks. Yet, many Americans are willing to take their chances.

Health plans, though, are hesitant to approve payment for experimental treatments. It can surprise patients to learn that their health plan does not cover the treatment, even with their doctor’s recommendation. Facing steep out-of-pocket costs to participate in a trial, patients are often upset to choose between prohibitive costs and their health.

But like anything in health care, the answer is not simple. While health care is deeply personal to all of us, health plans are tasked with making decisions that are in the best interest of all its members, which is not often easy. Here’s why experimental plans sometimes are denied:

  1. Standard of Care

Health plans follow third-party, unbiased, well-researched standards of care when making coverage decisions. These standards help inform which treatments are most effective for which diseases and which patients while ensuring consistent coverage across all members. Clinical trials try to figure out how new treatments should best be used while using members for research. Health plans need a level of certainty that a treatment will work in order to cover it. For more information on standards of care, check out www.hayesinc.com

  1. Risk vs. reward

While an individual patient might be willing to take the risk of a treatment not working or even making their illness worse, a health plan has to think of the entire membership pool. With little or no evidence of success, an experimental treatment’s risks can outweigh the potential benefits. While the media often publicizes the rare cases of recovery, experimental courses of treatments are often much less miraculous and sometimes even harmful to the patient. A health plan will never stop a patient from participating in an experimental trial, but they cannot in good conscience take money (premium dollars) from a pool of members to try something that could end up doing more harm than good.

  1. Your health belongs to you; the care you receive may be defined by your employer.

The majority of privately-insured Minnesotans receive health care coverage through their employer. In some instances, employers directly negotiated with insurers the costs, coverage and benefits that will be included in the plans offered to employees. What these employers are willing to cover varies greatly from company to company and job to job. When experimental treatments are denied, it may be the employer who has chosen not to cover it, not the health plan. While employees often have little control over what’s covered in their employer-based plan, it’s important to be familiar with the benefits and understand how that applies to their health.

  1. Treatment varies widely among physicians.

According to a HealthBasics survey, 67 percent of Minnesotans think that their insurance provider should pay for whatever test or treatment their doctor orders. But what test or treatment your doctor orders can vary widely based on your doctor or even your location. Patients in St. Cloud are twice as likely to undergo back surgery than patients in Rochester who are more likely to be treated with physical therapy for the same injury, according to a Dartmouth Atlas Project analysis. For a health plan with this data, one doctor’s recommendation for a clinical trial is not always in the best interest of the patient.

Health plans continue to look toward innovative practices and treatments. In some cases even working closely with researchers and physicians to elevate a strong experimental treatment to a higher rated standard of care. A higher standard of care rating means employers are more likely to include it in their coverage and physicians are more likely to recommend it for treatment. This expansion of the treatment provides more research and minimizes the risk for the health plan.

Patients should also work closely with their health plan to review any experimental treatments and coverage. All health plans have a case management team to work with their members and get the most out of their health care.