(Off Topic) Managed Care plans may attempt to screen people from the benefits of biotech's discoveries.
Here's the short-term outcome of a recent local battle with Primera Blue Cross. At least the state insurance commissioner was on the side of the patient and the procedure, though no change is policy has yet resulted -- merely clear exposure of the problem.
I think this type of story has major implications for both our biotech investments and our families' health. It's interesting (to me, at least) that the dollar amount of the contested procedure is relatively small, $100,000 (and the Hutch will be "eating" $25,000 of that).
We're just beginning to face the need for policies and strategies to deal with
o access to biotech's discoveries
o affording the use of those discoveries.
Choices and hard compromises are inevitable.
Meanwhile, know (in advance) what your own policy covers
-- which may not be easy to determine.
This patient, James Ellison, has been campaigning for reform regarding disclosure.
In his case, he had precious little time to lobby for his rights.
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Anonymous donor steps in when insurer rejects surgery
Seattle Times 2/23/99
newsindex.com
An anonymous benefactor has donated the money a 37-year-old multiple sclerosis patient needs for a potentially life-saving procedure.
James Ellison of Covington will receive a $75,000 donation for a stem-cell transplant at the Fred Hutchinson Cancer Research Center. His insurance company, Premera Blue Cross, has refused to pay, claiming the procedure is experimental.
Hutchinson Center officials said the donor requested anonymity. The center previously agreed to absorb $25,000 of the $100,000 cost for the procedure.
"It's a happy day, but a sad day," Ellison said last night upon hearing of the donation. "My whole goal was to make Blue Cross stand up for what they said in my policy they would do.
"I never wanted to ask for one red cent from society. But this means there are some people who are so compassionate and so loving out there."
Blue Cross has said the procedure is experimental and therefore not covered by Ellison's policy. Ongoing studies have shown most of the nearly 50 patients in the United States and Europe who have had a stem-cell transplant have been helped by the procedure.
Earlier yesterday, Dr. Meredith Mathews, director of Premera Blue Cross, said his company would agree to an independent mediator deciding whether or not Ellison gets the transplant he needs to survive a rapidly progressing form of multiple sclerosis (MS).
Ellison initially was denied coverage for the procedure late last year. He and his physicians had appealed the insurers' decision, saying studies show the treatment is the only clinically viable treatment for him, and that the potential benefits outweigh risks.
Ellison was diagnosed three months ago and his physicians say he may have only a month or so more before the disease renders him ineligible for the treatment.
But Mathews said stem-cell therapy - which involves injecting basic blood cells into a patient in the hopes of creating a new immune system - is experimental in the treatment of MS. The disease is caused by the patient's own defense cells attacking covering of nerve cells.
Mathews said the insurance company's decision is based on the opinions of three independent neurologists and other physicians who reviewed Ellison's case.
State Insurance Commissioner Deborah Sennappeared yesterday at a press conference with Ellison, his family and members of Washington Citizen Action to publicize his plight.
Senn called Ellison's situation the most dramatic example of injustice in her career.
"This shouldn't be happening at all. Insurance companies, which have an economic stake in denying a procedure, should not be able to use the experimental issue as an escape clause," she said.
Contacted about the anonymous donor later yesterday, she said she was happy a donor has stepped forward.
"There are some good-hearted people in this world and I'm not surprised at the donation," Senn said. "Ellison is one courageous guy."
She has proposed legislation to require an independent third-party review of insurance denials on so-called experimental procedures. Senn also is proposing an emergency clause that would require insurance companies to render decisions immediately in cases where timeliness is critical to terminally ill patients.
"We're restricted in what we can do. It's the law that has to change," Senn said.
When Ellison, a father of four children who has been paying insurance premiums for 17 years, heard last week that his treatment had been denied for the second time, he and his family were devastated.
"My son brought me his piggy bank and asked if I needed all of it. He wanted to know if there would be anything left," said Ellison yesterday, brushing away a tear.
"And he wanted to know if that meant I was going to die. What can you say? I told him that we'll win and that his piggy bank would stay full. We have people helping us and as long as we have that, we have hope."
Today is Ellison's 37th birthday. The donation, he said last night, is a "pretty huge birthday present." |
