Sunday, May 18, 2008

HMO = Shut Up and Die

I have an HMO rant burning inside of me, and I simply have to get it out. My friend has a rare form of bone cancer, and nothing was working to shrink the tumor. She researched day and night and came across a doc in another state who uses CyberKnife treatment, which is a robotic radiosurgery system designed to treat tumors anywhere in the body non-invasively and with incredible accuracy. She told her oncologist about it, and he wrote up the referral to her HMO. They turned her down for out of state treatment, but they did refer her to two CyberKnife programs in their network. Both turned her down.

My friend is one of those kick-ass, never take no for a final answer types and appealed the decision to California’s independent medical review board. But she didn’t stop there, after all, this was her life at stake. She also began raising money in case she had to pay for the treatment out of pocket. As she told me, “Screw those insurance weenies. I’m little more than a zit on their butts. It’s is all about the bottom line and acceptable losses. Plain and simple, I’m expendable in their eyes, and I’m not going to let them kill me.”

Her answer was to contact all of her friends and family to picket outside the insurance office. Newspapers and TV crews arrived to cover the event. We weren’t out there all that long before word came down that, magically, her treatment would be approved after all, and oh no, their sudden reversal had nothing to do with our makeshift protest. Hmm.

In an even stranger twist, a doctor from one of the original hospitals who’d turned her down saw the newspaper article and directed his office manager to call my friend. His thinking was, why have her travel across the country when she could have the same surgery in her own hometown? Indeed. He was even more puzzled that a doc from his own hospital had turned my friend down. Clearly, she was a very viable candidate.

Long story short, she had the treatments, and is doing so well it brings tears to my eyes. But I couldn’t help but think about the docs that turned her down. Was the insurance company pulling their strings? After some sleuthing, I discovered the appeals data from 2007 shows that of the state’s largest insurers, including my friend’s insurer, independent doctors sided with the patients in only one third of the cases. Why would that be? Can I really believe (or trust) that HMOs are so efficient that there is never any need for an appeal? Or is there collusion going on? I’ve heard horror stories about how doc’s feet are put to the fire by insurance companies if they ask for too many tests. Just how “independent” are these docs anyway?

I’m tickled pink that my friend is going to survive and live a long time. I’m devastated and bitter that she had to fight so hard and create a media circus to do it. Does anyone really believe socialized medicine will be any better? I certainly don’t.


Anonymous said...

CyberKnife is an incredible technology and is FDA approved to treat tumors and other conditions anywhere in the body. And its applications are expanding. Another group (CyberHeart), founded by venture capital legend Dr. Tom Fogarty, is even working on a protocol to utilize CyberKnife for certain forms of cardiac surgery.

Bear in mind that this is a new and disruptive technology, which faces all of the usual hurdles erected by the medical establishment. If you are facing a cancer diagnosis, you owe it to yourself to do your own research. If you blindly rely on what your doctor recommends, it may, literally, cost you your life. Many of them still don’t even know about CyberKnife and others will pooh-pooh it simply because it doesn’t fit into the treatment protocols that they are already selling. So you really need to do your own research.

Here are two links that should help you get the information you need with respect to CyberKnife…

Also bear in mind that CyberKnife is not available in Canada and there are only a few systems in Europe and all of those are privately operated. Even though CyberKnife is less expensive that the traditional open surgery, chemo and conventional radiation paradigm, the socialized medicine systems of Canada and Europe are way behind the adoption curve, none of them currently offers CyberKnife. CyberKnife is available in Japan, but, thus far, the regulatory bureaucracy has limited its use to tumors of the head and neck.

So as bad as our system may (or may not) be, it’s even worse where the government calls all the shots. That is why cancer survival rates in both Canada and Europe are far lower than in the United States and why the Japanese chronically refer to their healthcare system as “death-by-delay”.

So, again, you need to do your own research, both with respect to your own treatment options as well as how certain proposed changes in our overall healthcare system actually work… or don’t.

And, no it won't be any better under a socialized system.

kab said...

I am glad to hear your friend is getting the treatment she wanted & needed many people probably would not have as much fight and smarts.

I think once the FDA approves a procedure or drug it should be mandatory for insurance companies to cover ..they really should just link the two systems for an insurance companies approval lists...I'd hope someone could change it to work that way but this is big BIG business that like you said mainly just cares about the bottom line in dollars and cents. Some like to claim Non-profit org. - WHAT A JOKE!!
It is quite disgraceful and disgusting the way they get away with denying a claim such as your friends..I am not a doctor and I'd guess case by case what is needed really varies but if someone could have the chance not to have to go through chemo by being treated with something such as the Cyberknife vs. going through chemo and a different type of radiology treatment..who dare have the right to deny that person their chance of survival and also possibly avoiding the awful stories heard of enduring chemo treatment...This treatment will probably be a much more accepted practice in the insurance community at some point BUT it has been out for yearsssss so WHEN !?

These are changes that would probably have to come from Congress but we'd need some good people with some common sense to really fight for a bill as such.
Maybe someday.

Lynn Price said...

This treatment will probably be a much more accepted practice in the insurance community at some point BUT it has been out for yearsssss so WHEN !?

The fact that the treatment has been an accepted practice wasn't the issue in my friend's case. It was because the HMO didn't want to pay for it, and (we believe) found two docs whose feet were held to the fire and "encouraged" to say she didn't qualify. If she died, big deal.

#1 Dinosaur said...

You're spot on correct about the HMO part. They suck; that's all there is to it.