From syphax:
Death Panels
I was about to write a post about the following situation, but I'll just do a comment, instead- it's on-topic.Death Panels already exist (though I generally avoid inflamed rhetoric, this Death Panel meme needs to be converted to good use) in the private insurance industry.
I believe all of the following statements, though I haven't verified all of them personally, are accurate:
I know a man who has been battling a rare blood cancer diagnosed as histiocytic sarcoma (HS). He was a wife and young kids. His doctors at MGH, supported by second opinions at Dana Farber and beyond, agree that a stem cell transplant is his only hope for long-term survival.
He was scheduled to be admitted for the transplant on 10/19, but his insurance, Blue Cross Blue Shield (BCBS), has denied a second appeal for coverage of the procedure because it is not a “medical necessity” and cites “lack of evidence documenting the efficacy of this treatment.” Because of the rarity of this disease, such evidence simply doesn't exist for HS, but there is one known HS survivor who is now living 11 months after his stem cell transplant. Without the transplant, he will not make it many months past his next disease progression. There is a small window of opportunity to perform the transplant now.
This man's wife is pursuing the following list of actions. If anyone reading this has any other leads, contacts or ideas, please let me know.
1. They are submitting a consumer appeal to BCBS – File this by Friday at the latest. For terminal illnesses, BCBS must reply within 5 business days. While they are considering the case, it would put some pressure on them to receive inquiries from the press or BCBS upper management. Doe anyone know anyone with media or PR contacts? Is there a cancer story in the works that this could be part of?
2. They are submitting letters to Senator Kirk's office as well as Congressman Tsongas's office. Doe anyone have contacts in those offices (or others we've not thought of) who could bring attention to our case?
3. They are looking for an attorney experienced in successfully overturning insurance denials. Referrals would be useful. Area of practice would be “health insurance denials.”
4. If the BCBS consumer appeal is denied, the next step is MA's Office of Patient Protection. They will conduct an external review. Does anyone know anyone in that office? Or have any experience with the external review process?
5. They are in contact with Coakley's office. They said the family should come back to her at that point if these other avenues are not useful. I'm not sure what the attorney general's office would do, but she said to call again.
Beyond this, has anyone reading this had experience fighting health insurance denials? It would be useful to know which steps might be more favorable towards this case.
Also, where there are grey areas in the interpretation of the policy language, what other factors are most persuasive to the insurance companies?
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Now, I have BCBS insurance myself, and have always been quite happy with it- I'm not trying to smear BCBS, I'm just trying to get this family help (and point out the need for health insurance reform- it's not health care reform, folks. it's health insurance reform). My father died of a rare disease when I was 6, so I get particularly upset when I know of other children facing the same outlook.
Discuss
13 Comments . Leave a comment below.why not try him?
Kind of a different animal. Now he's at GLAAD in DC.
The folks at Health Care For All do advising on insurance issues. http://www.hcfama.org/index.cf...
died in childbirth when I was five years old. I feel for this family. We were never the same again.
In terms of getting help, scattershot is the word of the day. Get help - your state rep, your state senator, your federal representative and Senator. The Governor. No fooling around. Publicity is what helps change minds. Reach out to columnists, editorial panels and anyone who will listen. There's no time to "play nice."
It doesn't do any harm to "demand excellence." If you accept mediocrity, your friend will get less than that. Go for the gusto. You've got nothing to lose.
I do know of a few attorney advocates, and I will reach out to them on behalf of your friend. I don't know how much experience they have with external appeals...but I can check. I'll be in touch soon. In the meantime...pray. I'll be at Arch Street on Monday.
BCBS MA is supposedly a non-profit public charity. They are denying this man access to life-saving treatment while at the same time BCBS MA pays their CEO Cleve Killingswoth over $3Mil a year. Mr Killingsworth is simultaneously paid to be an executive with the National BCBS Federation in Chicago.
These abuses exist with regards to BCBS MA Vice President Andrew Dreyfus, too--he's double-dipping, being paid by "non-profit" BCBS MA, a public charity so it's heavily subsidized by us taxpayers, while he's also being paid to be an Exec. for BCBS National that includes For-Profits. Their "business strategy" is to increase market share and profit and this is done by diverting health insurance premium dollars away from actual health care services, such as denying this man recommended cancer treatment.
I'm a nurse who started out 15 years ago working in oncology and know many patients whose cancers have been cured by transplants. The state nurses association (MNA) and the state medical society (MMS) should be willing to advocate for this family, too.
I suggest that you contact Mobilize for Health Care to help organize a Sit-In at BCBS MA and to do media outreach to help this patient and his family. Time is of the essence. Personal and corporate profiteering and fortune-making by denying care to sick patients MUST STOP.
Maybe it's time to add Boston to the list of Sit-Ins to Stop Insurance Co. Abuses.
You may wish to read up on the following case that has been in the news lately. The Sarksyan's daughter's plight echoes that of your loved one. The glaring light of publicity is something insurers detest, so the more pressure you can apply to BC/BS of MA is beneficial.
All things are not equal in cancer. My son's father died last year at 46 of metastatic breast cancer that was originally diagnosed when he was 35 years old. Although breast cancer in men is relatively rare, about 1000 cases a year, the treatment is the same as that for women. At the time Dan was diagnosed, our only child, a boy, was 10 months old. After his initial surgical treatment and a chemotherapy clinical trial that eventually became the clinical treatment standard, he remained cancer-free for ten years. He had ten healthy years, too. He rode several times in the Pan-Mass Challenge, climbed mountains both in New Hampshire and Colorado, and hiked, by the time of his death, thousands of miles. Then the other shoe dropped, and it was downhill rather rapidly from there; in 18 months he was gone, leaving an 11-year-old son, and me, behind.
I have to say, too, that at the end of Dan's treatment, his chemotherapy was extraordinarily expense as his disease had metastasized to his brain and major organs. I do remember seen one paid invoice for a prescription that cost $1500/pill--and he took a lot of them. Every treatment option recommended by his oncologists was covered, no questions asked by Harvard Pilgrim Health Care. Dan was assigned an advocate from HPHC who helped us navigate the system so that Dan had what he needed when he needed it. She even intervened to move appointment dates up for Dan when the wait seem emotionally too difficult and arranged for some counseling for us as a family. I can't even begin to calculate the bill for Dan's treatment over the course of his disease, but I have to say I never once received a bill or a rejected service. We were incredibly fortunate--and we know it. Dealing with his end-stage disease with a little boy was hard enough. Having to deal with THAT on top of everything else would have been impossible.
So many people are touched by these diseases and these stories, so the more people you and your loved one's family reach out to, the more likely you are to be heard. Keep trying.
Your rhetoric is inflammatory but also quite correct.
The (de facto) death panels run by private insurance companies are the only death panels real or proposed.
The only people who actually support death panels are those who support the existing system of private insurance.
You might just hear how the folks at Medicare handle costs. The doctor might tell you Medicare people just ignore the approval request until the patient "goes away". Problem solved.
This is a serious consideration. How long can a patient be kept from dying? Thanks to technology, a patient can be kept on life support indefinitely. All the time incurring costs that might save another life.
How long do we keep people alive? I understand why the health insurance industry wants it as short as possible to keep costs down and profits up, but the government will have to tackle costs when 350 million potential patients line up for care. Robert Reich touched on this a few years ago.
Do we want to work on the problem now or have a Terri Schiavo circus mentality for each and every patient? Do we even consider the quality of a life? While I'd like to be a Pollyanna and say that all life should go on forever, there is a time to say goodbye.
Carl Sandburg:
"Our lives are like a candle in the wind."
if we know of a survivor who had a transplant, it's important to find out who this person is, find out what insurance, if any, covered it. There's the empirical support for the transplant. Doing less than that is medically unsupportable.
just might lead to death. Just a mandatory swine vaccine thought.
is taking up the cause of someone with a rare disease whose care isn't being covered. You might see if your friend can get some publicity from a group like that.
I was a little disappointed to get no responses to my initial comment itself, so I am gratified to see this discussion.
I saw and spoke briefly with the family in question on Saturday morning, when they brought their daughter out for pre-K soccer (I coach/herd cats). They are going ahead with the procedure regardless of what happens with coverage. They've also received a lot of support and offers of help through various channels, so we'll see.
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