Insurance Won't Pay NorCal Mom's Cancer Treatment

[Dion]

In late April, Shelly Andrews-Buta was scheduled to undergo treatment for breast cancer that had spread to her brain, threatening her life.

But instead of having doctors working to remove her brain tumors on the day the surgery was scheduled, she sat in a San Francisco hotel room. Why? Because at the last minute, her insurance company, Blue Shield, decided it wasn't going to pay for the treatment her doctors at UCSF Medical Center had recommended.

Andrews-Buta was stunned. "I mean this is my life, this is my life, this isn't, gee, if we don't do it you're just going to have a cut that doesn't heal, this is you're going to die," she said.

Without treatment, her doctor told her she in fact would die: tumors had invaded 15 separate areas in her brain.

Just two weeks prior to the scheduled date for surgery, Andrews-Buta could still walk. Now she's almost paralyzed and unable to walk without assistance.

Dr. Sneed told her that her best chance of survival lay with a high-tech machine called a "gamma knife."

Blue Shields response

"Blue Shield makes medical necessity decisions based on what is the most appropriate safe and effective treatment. To do that, we rely on the best evidence-based medical research available and the clinical opinion of medical experts. While we approve of gamma knife surgery when appropriate, in this case, the most appropriate treatment is whole brain radiation therapy, which we would approve for medical necessity if requested."

http://cbs5.com/local/cancer.treatme...2.1007394.html

My heart goes out to this gal and her family

[FlamesAddiction]

I that literally makes me feel sick just reading that. Don't know what else to say about it.

[Dion]

Originally Posted by FlamesAddiction

I that literally makes me feel sick just reading that. Don't know what else to say about it.

Makes you wonder if the bottom line is more important than a human life

[jtfrogger]

Isn't this type of rejection by an insurance company a relatively common occurrence in the US?

[FlamesAddiction]

Originally Posted by Dion

Makes you wonder if the bottom line is more important than a human life

Yeah, it would suck knowing that whether you live or die depends on a decision being made likely based on how to save billionaires a small amount of money.

The fact that the method the doctor wants to use is generally approved by the insurance company, but they want her to go against her doctor's recommendation is just plain weird.

[Iowa_Flames_Fan]

Originally Posted by jtfrogger

Isn't this type of rejection by an insurance company a relatively common occurrence in the US?

It is. The insurance companies will retain actual staff members whose job it is to find ways to deny claims. It happens routinely with smaller bills, where consumers will often just say "F it" and pay for the service themselves, even if they're not getting the coverage they were promised. But there are high-profile cases like this one where an insurance company will deny coverage to someone who needs life-saving treatment, often based on either a technicality or on their interpretation of what is and is not an appropriate treatment.

One of the funniest (in a dark, awful way) arguments against single-payer health care that I used to hear down there was "I don't want a government bureaucrat standing between me and my doctor." Apparently an insurance company bureaucrat is better for some reason.

[Tower]

This is sick. People say we are lucky in Canada to have what we have, I can agree to that. If the people in the USA stop letting Corporations rule their lives things will get done. The problem is it is easy to say but harder to do...

This reminds me of "Sicko" Documentary. Moore is great IMO.

[Cowboy89]

It's one thing to jump solely on the insurance companies, but in reality this is the end-game of a recurring problem that has multiple actors.

Step 1: People get insurance to cover medical and drug expenses.

Step 2: Because insurance pays for it and not the person on the spot the Hospitals, doctors, drug companies et al jack their prices into the stratosphere.

Step 3: To keep costs down insurance companies deny claims and add legal jargon to allow them to escape paying claims.

The cycle continues until costs get so high that a lot of people are uninsurable at reasonable costs, and those that are insured do not get appropriate care.

[Cowboy89]

Originally Posted by Tower

This is sick. People say we are lucky in Canada to have what we have, I can agree to that. If the people in the USA stop letting Corporations rule their lives things will get done. The problem is it is easy to say but harder to do...

This reminds me of "Sicko" Documentary. Moore is great IMO.

Does being a 'Freeman on the land' obsolve one from the decisions made by an insurance contract?

[Tower]

Originally Posted by Cowboy89

Does being a 'Freeman on the land' obsolve one from the decisions made by an insurance contract?

Does your lack of understanding your own rights bind you to yours?

Oh and it's Freeman-on-the-land... Learn it.

[Iowa_Flames_Fan]

Originally Posted by Cowboy89

It's one thing to jump solely on the insurance companies, but in reality this is the end-game of a recurring problem that has multiple actors.

Step 1: People get insurance to cover medical and drug expenses.

Step 2: Because insurance pays for it and not the person on the spot the Hospitals, doctors, drug companies et al jack their prices into the stratosphere.

Step 3: To keep costs down insurance companies deny claims and add legal jargon to allow them to escape paying claims.

The cycle continues until costs get so high that a lot of people are uninsurable at reasonable costs, and those that are insured do not get appropriate care.

I agree. Insurance companies get a reputation as being "evil" because they are interested only in the bottom line--but if they're evil then so is capitalism. They'd be negligent to their shareholders if they weren't thinking of ways to make their operation more profitable.

However, they do make an easy scapegoat for anyone who's not interested in real health care reform, but is interested in the political benefits they might be able to get from the issue (read: Democrats). Unfortunately, what's actually needed is for the U.S. government to admit that the current model has failed in a spectacular, wholesale fashion--and they need to burn the whole thing down and rebuild it according to a new cost paradigm. I don't know what it will take for that to happen--probably it never will.

[Dion]

Originally Posted by Tower

This is sick. People say we are lucky in Canada to have what we have, I can agree to that. If the people in the USA stop letting Corporations rule their lives things will get done. The problem is it is easy to say but harder to do...

This reminds me of "Sicko" Documentary. Moore is great IMO.

You should meet my sisters b/f. The 2 of you would get along great with your conspiracy theories.

[Tower]

Originally Posted by Dion

You should meet my sisters b/f. The 2 of you would get along great with your conspiracy theories.

PM me his contact after you get permission from him.

[Devils'Advocate]

I worked for an HMO for a year.... I spent most of my time writing code to deny claims. ie if someone sees a psychiatrist and doesn't like him, sees a second psychiatrist and doesn't like him either, then the patient is on their own. So I had to program into the system to check if they had psychiatric claims with other doctors and automatically deny the claims with the new doctor. I bet most of the people who went to see a third psychiatrist didn't know that was in their insurance. And they end up paying out of their own pocket.

We had "business experts" take the legalese in the insurance agreements and explain it to us programmers to do the automatic denials. When I saw what portion of the claims were actually getting paid out at the end of the day it was horrendous. I left the company for many reasons, but absolving my conscience was one of them.

[Phanuthier]

Living in the USA for almost a year, I think health care + capitalism is a bit of a dirty business. I can see why the insurance company does what they do, and to make their money, yes they do value $ over life. I understand that so this doesn't really confuse me. However, I really don't agree with mixing health care + capitalism for sure, give me Canada's screwed up health care system over USA's trashed health care system any day.

(one of my cousins is actually a doctor at UCSF working in long term care I think, I wonder if is this womens doctor)

[HotHotHeat]

Cue the Obama administration using this as an example for universal healthcare...

I agree with others here, this problem is as much the fault of the health professionals as it is the insurance companies. For profit health care FTW....

[Tower]

Originally Posted by Devils'Advocate

I worked for an HMO for a year.... I spent most of my time writing code to deny claims. ie if someone sees a psychiatrist and doesn't like him, sees a second psychiatrist and doesn't like him either, then the patient is on their own. So I had to program into the system to check if they had psychiatric claims with other doctors and automatically deny the claims with the new doctor. I bet most of the people who went to see a third psychiatrist didn't know that was in their insurance. And they end up paying out of their own pocket.

We had "business experts" take the legalese in the insurance agreements and explain it to us programmers to do the automatic denials. When I saw what portion of the claims were actually getting paid out at the end of the day it was horrendous. I left the company for many reasons, but absolving my conscience was one of them.

And I bet your knowledge can bring a company as sick as this down to it's knees.

My heart goes out to this woman, and I trust many will reach out and support.

[Iowa_Flames_Fan]

Originally Posted by HotHotHeat

Cue the Obama administration using this as an example for universal healthcare...

I agree with others here, this problem is as much the fault of the health professionals as it is the insurance companies. For profit health care FTW....

There are two problems with your post, as I see it.

1. Obama has proposed health-insurance reform according to a Massachussetts model. What he is getting from Congress is a mish-mash of pet projects and new health care spending, with not a shred of real health care reform to reduce costs. "Universal Health Care" was never even on the table. You can agree or disagree with what he's trying to do (I disagree with it, but for different reasons than many) but we should at least agree on what it is: it's a variation on the system that they have now, and leaves in place the biggest plank of the health care system in the U.S.--the insurance companies.
2. What Cowboy89's analysis actually reveals is the failure of for-profit health care to provide the system with the resources it needs, allocated in a fair and equitable way. Profit and health care are uneasy bedfellows at the best of times, but it's the profit motive that is killing this woman in California--and she's not the only one. Health care should be provided by doctors--when it starts being provided by insurance goombahs and hired-gun lawyers, you have big problems--the biggest of which is skyrocketing costs across the board. The U.S. Health Care system has many flaws, but perhaps its most grievous is this: it's not sustainable. Costs will eventually escalate to the point where the system will collapse and people will begin to opt out of it--which is kind of already happening.

[mykalberta]

Is gamma knife considered experimental?

I can see why they would reject it based on costs because those things tend to be bloody he77 expensive. And while it may be the better procedure than full on brain radiation why does this one patient deserve this treatment and not others. And if they do would the costs for this procedure if it became more widely use bankrupt these companies.

Hopefully this doesnt turn into a Medicare vs US Medicine because I doubt the gamma knife is even available up here.

[Dion]

Originally Posted by Tower

PM me his contact after you get permission from him.

I was being sarcastic. There's no way i'd give you his contact info.