Big Insurance Met Match When Turned Down a Lawyer's Request for Cancer Treatment
propublica.org
propublica.org
They didn't reverse the decision until we got a lawyer who knew the ins and outs of the appeals process. Thankfully, we were able to work through that fast enough for treatment to be effective... there's no way we could have paid out of pocket.
The ability of an insurance company to unilaterally deny treatment, or determine what type of treatment a patient receives, is obscene and should be categorically illegal. There is no instance in which a medical bureaucrat should should be able to, sight-unseen, overrule a patient's own doctor.
It's so frustrating.
Not everyone wants to pay top dollar for the most comprehensive gold-plated plans.
it is, but i imagine the insurance company is expecting a certain cost for some expected treatments, and use that to calculate your life-time value as a customer. If a new treatment that has better outcomes, but is more expensive comes along, the insurance company may stand to lose money, and thus, they prefer denying such a treatment and only offer the "old" one.
At least, that is how i would rationalize the behaviour. Whether this is actually the reason or not, remains to be seen.
Socialized medicine certainly has its issues, but if there has to be a "death panel", I'd rather it be composed of doctors than a bunch of bean counters.
https://en.wikipedia.org/wiki/Amanda_Pritchard
Even if the chief was the doctor, they would be getting their funds from the political leaders, who are most likely not all going to be doctors.
Similar for a close family member with a strange heart and immune condition.
InsuranceCo BCBS had some bureaucrat without even a medical degree directly second-guessing the tests ordered by the literal Director of Cardiology at the world-renowned Mayo Clinic.
All I can think is: "Who the fck are you to even begin to question this expert, and deny his recommendation?". Now, IFF they had some actual peer reviewing it (e.g., the head of cardiology at Cleveland Clinic or Harvard Med School), that might be legit, but this is nothing of the sort. It's like the tech giant's arbitrary terminating accounts with support, except instead of cutting off your livelihood, they are killing you.
It is the death of expertise. It seems like practicing medicine without a license and without even seeing the patient (which is legally required before writing many prescriptions).
Why it is even close to legal is utterly baffling.
(I hope your dad continues to recover)
I think American healthcare is insane… and the slow sliding in the American style healthcare direction I see in the UK and even slower slide here in Australia, this slide is largely borne out of American healthcare business having no more room to expand and trying to export their business model overseas to expand their addressable markets… it’s insane to allow non medical professionals… to allow armies of accountants and actuaries… to decide how to treat patients.
It should be criminal, but it won’t be because the healthcare industry in America is so broken it will lobby till it’s broke to continue to be allowed to remain broken otherwise it might not be as profitable.
I think a licensed doctor/pharmacist employed by the insurance company has to make the decision, although, since they do not have liability exposure, I can imagine metrics can be imposed on them that make the quality of their work less than desirable.
If I don’t want to pay I can have a GP appointment with a short trip and a little wait sometime in the next 1-3 days… if I’m happy paying $40 Australian … I’ve got a GP appointment within walking distance tomorrow, no issues no bullshit, and I’ll even get some of that back from the government if I can be bothered, because anything that urgent is probably worth the money lol.
If I want to pay I can get specialist treatment, I’ve got private healthcare to cover fancy shit like regular physiotherapist sessions due to having an office job which will slowly and stealthily destroy your body no matter how careful you are… and glasses if I eventually need them… and stupid levels of dental because that’s my personal preference, if someone ever smashed out all my teeth I’m just completely covered … and that’s all on top of basically being assured care for anything serious disease or critical injury related by public healthcare… it’s just obviously the better arrangement. The most general risks are shared by the biggest pool of people paying for it… everyone paying for that with their taxes. If you want more… your free to buy it, and a lot of people do! It works great.
My Mum was diagnosed with Stage 4 lung cancer, and they went all out with radiation, chemo, experimental new treatments and a TON of tests and scans. They estimated she had 12 months to live, she made it just under three years and had basically every treatment and scan even conceived to fight cancer.
Money or insurance were never even discussed or mentioned once. It's simply not part of our world.
The US can do better.
I emotionally agree with this, but I don't have a good answer for the following situation:
1) A company develops a new, slightly more efficacious treatment, patents it, and prices it at some completely absurd cost (say, $1 million/month for daily pills).
2) Doctors understandably prescribe this treatment because it's slightly more efficacious than the pills that cost $16/month.
Where would pricing pressure come into play here? If insurance companies can't say "No, that price is ridiculous and we're not paying it." I'm honestly wondering what the solution for this would be.
Also, rarely is it the case that such expensive treatments are needed by more than a fraction of the population. I’d say there’s an argument to be made that we all aught to be okay with a small fraction of people getting healthcare that far outstrips their contribution via taxes – given that we never know if that one day may be us.
Yes, but that still must have limits. Society certainly should not pay one trillion dollars to care for a single patient. That’s too inefficient.
> then why shouldn't we?
Ultimately, there's only so much economy to go around. What percentage of it are you willing to dedicate to treating that one condition? What about everything that can't be funded or produced as a result of that allocation?
But that is the purpose of high deductible health plans, to give healthcare recipients an incentive to to visit cheaper healthcare providers or accept generic medicines.
Technically, the insurance company is denying payment, not the treatment. Also, many times, the prior authorization requirements and formularies are given by the insurance company’s customer, such as the the government (Medicaid, Medicare, employer, etc). But the insurance company will take the heat, because that is part of what they are getting paid for.
Useful for when you need to give a Senator quick access to top tier healthcare, and older people a lower level of healthcare, and poorer people an even lower level of healthcare.
For almost every person in this country, for an expensive treatment, this is a distinction without any difference whatsoever.
Was it BCBSLA that chooses to use Elevance for reviewing claims and the guidelines for those claims? Or does the federal government dictate using Elevance? And are there varying federal government standards for different insured populations?
I have not researched it thoroughly, but I can envision a situation where BCBSLA sells the government a “fall guy” role, and the government (taxpayers) save money by telling BCBSLA to use a more restrictive formulary or prior authorization criteria for certain populations.
Yes.
The difference is how much choice you have for your death panel.
They don't actually exist anywhere (else) afaik.
(edit:
I found a speech by Stephen Hawking on the matter:
https://www.hawking.org.uk/in-words/speeches/speech-1
Quick summary: At the start of the speech he refutes a claim that death panels exist in the UK NHS and that they would have let him die. Of course the strongest refutation is the fact that he was at the time -in fact- quite alive; thanks to the NHS.
)
It’s not disputed nor unknown that a variety of expensive/newer cancer treatments are not payed for by the NHS. I posted one example but there are many
At some level, the reward-to-risk ratio is too low.
The difference is, that insurance costs a fraction of what it costs in the USA because the basics are all covered and the cost of providing state of the art care is drastically reduced since the hospital facilities/bed are still covered publicly.
Almost made me even more frustrated. I was hoping they'd have to pay up big time, or that some legal precedent would be set in his victory that would help millions in the future avoid this mess.
Also title could use a 'treatment' added to it.
They did not even receive a partial payment yet, though, 5 years after the event.
>The case itself remains open. The judges ruled that Blue Cross must pay for Salim’s treatment. But they did not say how much.
>Salim is expecting the full $95,862.95 he paid. However, court records show that Blue Cross has said it only needs to pay Salim the discounted rate it had negotiated with MD Anderson at the time of his radiation treatment: $35,170.47. That’s what Blue Cross would have paid if its doctors had said yes in the first place.
>A decision is expected later this year.
Shows you how much you should depend on the courts if you are not already rich.
Trial attorneys have a very peculiar reputation in Louisiana. They get incredibly wealthy on the backs of lawsuits against the state's oil and gas businesses and their insurers, then turn that money into political lobbying power. This creates a populist dynamic where trial attorneys try to rally voters to oppose tort reform laws in the legislature that are often backed by insurance companies.
For instance, in the Louisiana gubernatorial election, where Salim shows up in this article: https://www.nola.com/news/politics/jeff-landry-is-collecting...
However, the patient never would known about it because it wouldn't have been on the list of "approved therapies", so the doctor never would have suggested it.
The article dances around it, but for this particular cancer, proton beam therapy has little evidence supporting it. The current treatment guidelines like NCCN list a number of evidence-based therapies for first line, second line and subsequent line treatments. Proton beam thereapy is a "hail mary" and universal healthcare systems are less expensive than the US because they don't pay for "hail marys".
So in places like Canada (whose patients, it's important to note, need to travel to the US because there are no proton beam centers) the doctor wouldn't have even considered it as a treatment option in this case.
I see the price of proton therapy varies wildly between thousand and tens of thousands of dollars per treatment. Still too high. Perhaps if the cost were lower and some streamlined review process existed, it would be less of a lift to say “hop on the table while the accelerator spins up, won’t be expensive if this doesn’t work.” (in this example) Rationing human supply (labor) makes sense, making humans takes time and supply is constrained. Other costs can be ruthlessly driven down (with some combination of manufacturing learning, research, etc). Consider the costs of Western disease (obesity) and bariatric surgery with recent developments in semaglutide, for example.
On what basis are you claiming that the cost of proton beam therapy is not too high?
You state that non-US healthcare "wouldn't have paid for this either", but later you mention "need to travel to the US because there are no [PB] centers" (which is true). But then you continue "the doctor wouldn't have even considered it as a treatment option".
Now, I'm not an expert at PB treatment, but the fact that patients have to travel would suggest that at least some do that; I'm not sure if the treatment is partially or fully covered. But a quick Google seems to suggest that this option is known, and that there is lobbying to create such a center in Canada; and they acknowledge that the treatment, lasting 6-8 weeks in a distant city can be challenging.
But if it isn't an option considered or offered, why bother to build something with no demand?
I said "in the case of the patient in the article".
Proton beam therapy is in the clinical guidelines, just not first line for throat cancer (or at least not right now, maybe future evidence will prove otherwise).
What concerns me is "This rapid growth in the number of proton beam therapy centres, [...] is viewed with concern by advocates of evidence-based medicine. " [1]
It seems like Proton beam therapy is still -as yet- somewhat controversial.
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6474264/
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8130814/#:~:tex...