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"A lot of this is UniCare basically administering the rules based on our customer, in this case the Group Insurance Commission."
--Tony Felts, spokesman for Unicare
Hannah Coler is an Amherst native and UMass student. She was diagnosed with diffuse sclerodoma. Because the disease, which hardens the skin, and eventually the internal organs, is progressing rapidly in her case, Coler's doctors think she should "participate in the Scleroderma: Cyclophosphamide or Transplantation, or SCOT, trial." Unicare, Coler's father's insurer, however, and Group Insurance Commission (GIC) to which it belongs, say NO.
The Daily Hampshire Gazette reports:
The SCOT trial patients take one of two treatment routes: either high doses of the chemotherapy drug Cytoxan or a stem cell transplant. The trial compares the results of the two for mortality and organ damage.
UniCare officials, in three separate letters, wrote that the SCOT trial is not a covered benefit.... The insurance company considers the SCOT trial experimental, says it's not medically necessary, and maintains that it lacks evidence of effectiveness. The Colers received a denial letter from UniCare stating, in part, "The fact that a physician ordered it or that this treatment has been tried after others have failed does not make it medically necessary." Tony Felts, a spokesman for UniCare, said health plans often contain exclusions for coverage pertaining to medical trials. "A lot of this is UniCare basically administering the rules based on our customer, in this case the Group Insurance Commission," Felts said.
In a sad twist of fate, Coler's father had switched from Blue Cross Blue Shield to UniCare so the family could see doctors outside of network. Other providers available to Coler include Blue Cross Blue Shield, Cignet, and Uniform Medical would have provided coverage for the SCOT trial. When the Colers appealed Unicare's decision, the GIC sided with the insurer.
GIC Executive Director Dolores Mitchell wrote, in a Nov. 12 letter, "I regret that the appeals committee decision could not be more favorable to you and Ms. Coler, but the language provided on the SCOT trials Web site establishes that this trial is investigational and that the treatments provided are not standard medical treatment for systemic scleroderma." Andrew Coler disagrees. "The SCOT study is the only proven, and most effective, treatment," Coler said. "It's got a very good track record, and it's documented that people have made a full recovery."
From a soulless, cost-benefit point of view, I don't know if the experimental treatment requested by 21 year-old Hannah Coler and her doctor is worth it. I'm not an ethicist or an insurance company. I am a parent, however, and if there were a $300,000 treatment that gave my daughter a chance at life, I'd want it. Cost-benefit analysis be damned.
As case of Hannah Coler demonstrates, rationing is alive and well and living in the private sector. It's even endorsed by our quasi-independent representatives at the GIC. Rationing health care is already part of the insurance game and the stakes are life and death.
You can donate to the Help Hannah Coler Medical Fund here.
Mark
4 responses so far ↓
1 Akula
// Nov 28, 2009 at 2:50 am
Had to chime in on this.
Based on what you've written here (and the way you've written it) you seem to be implying that you're in favor of the "health care reform" currently being considered by Congress. Further, you attempt to make a connection with what you call the health care rationing in the "private" sector. So, I assume your position is that the fears about the currently-tabled health care reform and how it will lead to excessive "rationing" are unwarranted . . . because we already have rationing?
Yet you cite an article about the Group Insurance Commission -- an entity set up to provide health coverage to state workers while attempting to limit the cost of same -- as your example? You can't be serious. By excerpting the Gazette article are you really proffering the idea that a "commission", which was set-up by the Legislature (government), and which is currently denying coverage for a procedure to a covered member, is going to bolster your contention that we NEED health care reform of the type currently being debated in Congress? The type of health care "reform" which will almost certainly lead to . . . more rationing?
This post of yours makes no sense. Incredibly, the very article you excerpt provides evidence, if not outright proof, that the position you have taken is untenable. After all, if the THREE private insurers noted provide coverage for this procedure, and what is essentially a government-run "commission" doesn't, how is that possibly an indictment of the "rationing" that goes on in the private sector and simultaneously an endorsement of the morass that awaits us all (including far, far more rationing) if any of the current versions of health care "reform" actually pass?
Again, if I've misinterpreted your intent please feel free to clear it up for me.
2 Mark Bail
// Nov 28, 2009 at 6:41 pm
Your reasoning is spot on. I don't know about far, far more rationing, but I'll agree to my reasoning being sloppy. If countries like France and, I think, Germany, or England, for that matter, are any indication, even a single payer insurance plan wouldn't outlaw supplementary or private insurance. If any public option makes it through Congress, it will be insuring people who would otherwise have no health insurance. Whether it turns out to be better than no health care remains to be seen, but my money's on people with no insurance being happier and healthier. [I edited this comment Saturday night].
As you'll see from my next post on the GIC, my motive is mainly political and part of a larger fight on behalf of Granby and Hampshire County. Just as federal health insurance reform could complicate Massachsetts' and Hawaii's intiatives, moving municipal employees into the GIC may be not be the money saver our legislature thinks. Our Hampshire County of Governments has an insurance program that beats the GIC's costs and prices.
Thanks for your comments.
Mark
3 Akula
// Dec 1, 2009 at 2:01 am
"If countries like France and, I think, Germany, or England, for that matter, are any indication, even a single payer insurance plan wouldn't outlaw supplementary or private insurance."
No. Such options may merely be priced out of existence in their efforts to compete with a government program that can always change the cost-benefit rules as it sees fit, since it ultimately will have no genuine "bottom line" to which it need answer. Never mind the inequity present in a new health care system that would tax all for a program that may not meet everyone's needs. Otherwise, why would a person need any "supplementary" insurance at all?
"If any public option makes it through Congress, it will be insuring people who would otherwise have no health insurance."
Ahh, and there's the rub. The definition of "have no health insurance" is key in this context. Conservative estimates (no pun intended) put the true number of Americans who are uninsured -- because they genuinely can't afford it -- at 9, perhaps 10 million. The problem with the 35+ and 45+ million figures is that by subterfuge they include both individuals who aren't citizens as well as the vast number of Americans who CAN afford health coverage but for their own reasons choose NOT to purchase it.
"Whether it turns out to be better than no health care remains to be seen . . ."
True that.
You seem an erudite and learned individual and I would disdain putting words in your mouth. You don't come straight out and say it but I would deign to wager that you are, in the overall, in favor of government-run health care legislation. Contrarily, I posit that nearly ALL of the needs of the (genuinely) currently-uninsured could be met far more effectively were the forces of the market truly unleashed in this segment of the economy. The fact that we see no (serious) discussion in this direction -- permitting insurance company competition across state lines; establishing and enabling individual health care savings accounts; providing health insurance tax benefits to individuals and the self-employed identical to those granted to businesses -- tells me that this current effort is not truly about health care reform as much as it's about increasing the rolls of a dependent class, marginalizing (and eventually driving out of business) providers of private health insurance, and increasing the number of unionized workers in this country (which, outside of the government sector, currently stands at an all-time low).
"As you'll see from my next post on the GIC, my motive is mainly political and part of a larger fight . . ."
True -- this I could not have known. Further, I wish to state that I'm not without feelings for the person referenced in the Gazette story. My visceral reaction would have been similar to yours -- but if the solution to this problem is analogous to both of us coming upon a trail diverging in the woods. I guess you could say that while you maybe chose the path on the left, I chose the right one.
Peace.
4 Andrew Coler
// Dec 5, 2009 at 1:55 am
I am the father of Hannah Coler. Unicare and GIC has said "no" based on the procedure being “experimental” or “investigational”.
Without treatment Hannah has a 50% chance of being alive at 5 years. If she is a participant in the study her odds go up dramatically. In the Northeast site 50 out of 52 patients who participated in the study have had success with the treatment. Nationally 80% who receive the stem cell treatment got better, greater than 50% from the Cytoxan arm. What makes the Cytoxin arm much more effective then the conventional therapy is the dose and the duration in which it is given. Finally the SCOT study has been in phase 3 for over three years
She is not seeking coverage for “investigational”
or “experimental” treatment but rather a life saving and life changing treatment.
The fact of the matter is that the only
“investigational” aspect of SCOT, is a comparison of the two already proven effective therapies, Cytoxan (Tashkin, NEJM 2006) and
Autologous Stem Cell Transplant (Nash, Blood 2007). The effectiveness of both Cytoxan and Autologous Stem Cell Transplant,for the treatment of Systemic Sclerosis, has already been established.
The SCOT study simply seeks to investigate which of these treatments is the most effective!
Finally, there is at least eight years of supporting evidents of the SCOT study effectiveness and many insurance companies such as United Health Care, Blue Cross/ Blue Shield, Cigna recognize that the research supstantiates the ethicacy of the treatment.
Andrew