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Old 12-09-2008, 03:27 PM
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Harrison Harrison is offline
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Default The Insurance Intelligencer: 12/8/08

The Cure for Cancer


We donate for the cure. We research for the cure. We climb, walk, race for the cure.

When the cure is found ... it will be very, very expensive.

What good will that cure be, if your insurance won't pay for it?

********

One day, you are sitting in your doctor's office, worried and waiting. He tells you that you have cancer. What treatments will be offered to you?

What treatments will your doctor offer?

The ones that he happens to know about. He is not all-knowing.

The ones that he approves of. His criteria may not be the same as yours.

Generally speaking, he will offer the treatments that are available within the insurance network.

Disclaimer: Many of your doctors are providers for the insurance company, and will fight the insurance company if necessary in order to get the best treatment for you. We cannot assume that all doctors are doing this, however.

The insurance company is a business, not a social service agency. When you meet with your doctor, your are sitting face-to-face with the representative of the insurance company. It is his job to reduce operating expenses, by controlling access to services.

I am not being cynical. That is his job. He is the gatekeeper.

Of course, it is also his job to treat whatever medical problem you came in with. Sound like a pretty serious conflict of interest? It is, for all concerned.

The simplest way for your doctor to treat you -- while still controlling costs -- is to offer you whatever treatment is available on his list, in the network, by providers whose fees are determined by the insurance company.

What if your child has a brain tumor, and the only surgeon with the skill and will to remove the tumor does not happen to be contracted with your insurance company? I have news ... many of the most talented and experienced surgeons are no longer contracted with most insurance companies. Don't count on your doctor knowing about this surgeon, or telling you about him.


How do new treatments become standard of care?

Short answer? They don't.

Do you really think that your insurance company is putting forth a big effort to figure out how to shell out more dollars for expensive new medical treatments?


There is no path whereby treatments become "standard of care" for insurance companies. I fight every day for treatments that have been ...
  • FDA-approved
  • Tried, tested, and proven for thirty years
  • Studied in randomized trials
  • Published in peer-reviewed medical journal articles
  • Paid for hundreds of times by the insurance company
Yes. A treatment that Acme Insurance paid for will be denied by Acme insurance three days later as "experimental." Not only is there no path by which new treatments are evaluated and accepted by insurance companies ... they continue to deny treatments that they routinely pay for.

I have fought Regence of Washington six times over the past eighteen months for the same cancer surgery. Each time that a new patient needs this surgery, they call it "experimental" all over again.

How long will it be before the Medical Director of Regence in Seattle tires of receiving my 86-page faxes in the middle of the night? They will fund your effective, proven out-of-network treatment. But only if you are ready to fight for it.

McDonald’s or gourmet?

Much of this research seems to be focused around finding the "magic pill" to cure cancer. Preferably a pill with no side effects, one that my insurance will pay for. However, the likelihood of such a cure seems rather remote to me.

Meanwhile, many patients are having very good outcomes, with very advanced and difficult cancers. The treatment that saves them is not easy, sexy, exciting or new ... it is good old-fashioned skilled surgery.
For many of us cancer patients, surgery is still the gold standard, and surgery is the only path to long years of health with no recurrence.
The surgeon with the best outcomes is not always a provider for your insurance company.

In one of my recent appeals, the insurer denied an out-of-network cancer surgery, stating that the surgery was not "evidence-based medicine." This insurer was currently funding systemic chemotherapy for this patient to the tune of $40,000 to $60,000 per month, with no scientific evidence that it would benefit him. This chemotherapy would continue until the patient died, or couldn't tolerate it anymore.

Since you are spending so much dough anyway, I suggested, why not spend the $40,000 for the definitive surgery that might actually fix the problem?

I believe that I have finally figured out why insurers are so eager to recommend systemic chemotherapy, even in cases where it has never been found to help, and even though it is so expensive.

Each insurer delivers medical care to thousands or millions of people. Sort of like McDonald's, which serves food to millions of customers.

Why is McDonald's offering hamburgers, instead of soufflés?

In order to serve a thousand hamburgers, all you have to do is buy a big vat of nasty factory-farm beef, and deliver it to McDonald's. There, a revolving cast of interchangeable employees are able to turn out identical meals.

Preparing a soufflé, however, requires more expertise, and is more labor intensive. It requires a skilled chef, ready in the kitchen to perform at the top of his game.

In order to treat a thousand cancer patients, all you have to do is buy a big vat of nasty toxic chemicals, and deliver it to the medical facility. There, a revolving cast of interchangeable medical personnel are able to deliver identical treatments.

A curative cancer surgery is more labor intensive. It requires a skilled surgeon, ready in the operating room to persevere until all of the cancer is removed. Surgeries are longer, patients are sicker, and better outcomes are achieved. Not in keeping with the "serve the lowest common denominator" school of insurance-driven care.

Systemic chemotherapy is the best and most appropriate treatment for many people, of course. But not always, and not if the right surgery is more likely to yield a good outcome.

As long as private insurance is in charge, expect to be steered towards the McDonald's burger, not the soufflé.

Perhaps the only one who cares enough to fight for the extraordinary, above-the-norm care is you -- the patient whose life will be saved by it.

Ask me about my new

"Insurance Insider Secret Contacts List"

********

I know where the Medical Directors are hiding, and I've got their fax numbers!



Happy and peaceful Insurance Warrior-ing,

Laurie Todd
http://www.theinsurancewarrior.com/
ph: 425 497-1858
__________________
"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate