Insurers Routinely Refuse Payment on Life-Saving Treatment: NM Health Security Act Needed

Today, a stirring report on how health insurers rescind coverage when you get sick, routinely deny coverage recommended by your doctor and compromise your health….evidence why NM’s Health Security Act needs to be passed and signed in 2019.Today’s post describes what happens when corporate for-profit health insurers operate as a gateway to your healthcare.  Spoiler alert: it is tragic and provides yet another illustration of why capitalism and its sole priority being profit is ill suited to be involved in anything that involves human need.

Today’s post also points to the critical need for all of us to support and lobby for the NM Health Security Act (HSA) in January. The Health Security for New Mexicans Campaign has been advocating for this law for over a decade. Kudos to them for their tenacity, but it is time to get this done. Democratic Socialists of America has made the HSA their number one priority and as this post will illustrate, for very good reason. If you want to get involved in advocating for the bill, click here to reach the Health Security for New Mexicans Campaign. The site has information about the bill, how you can donate or how you can get involved. And now….a post that will motivate you to get involved.

Health Insurers Cost Lives.  Lots of Them & You Could Be One of Them

We start with a report from CNN.  Before examining how common denials of claims can be, a case study from a CNN report. Kate Weissman, a 33-year old who was diagnosed with 2B ovarian cancer, underwent 55 rounds of radiation, 17 rounds of chemotherapy and surgery to remove cancerous lymph nodes. But the cancer spread to her paraaortic lymph nodes, tucked behind the bowels and lying in front of the lumbar vertebrae and doctors felt that the the only treatment that could save her was proton beam therapy. Her medical team five of whom teach at Harvard Medical School and one  who is the world’s foremost expert in proton beam therapy, felt that the standard treatment would likely kill her and recommended proton beam therapy.

From CNN:  “The nation’s largest health insurance company, though, disagreed. UnitedHealthcare denied Weissman coverage for proton beam therapy after multiple appeals, saying “there is not enough medical evidence to show proton beam therapy is effective for your particular condition. One of the insurance medical directors who twice reviewed Weissman’s appeals wasn’t board-certified in “gynecologic oncology,” according to the American Board of Obstetrics and Gynecology, raising troubling questions about why she was involved in a cancer case.”
The doctors explained to UnitedHealthcare and to Kate why there wasn’t a number of randomized trials to demonstrate efficacy and what good evidence there was that the treatment could very well work. From CNN:  ” We don’t have a randomized trial, nor, Kate, are we ever going to have a randomized trial for this,’ he [Dr. Whitfield Growden] tells her. ‘Finding 100 patients with cervical cancer that spread to their paroaortic lymph nodes,’ Growdon says, ‘and randomizing 50 of them to standard radiation and 50 to proton beam therapy is just not plausible or feasible. We need to be innovative with our care as long as we fervently believe we can do it safely — that we’re not going to hurt you with it,’ Growdon tells her.  ‘While a randomized controlled trial does not exist, preliminary peer-reviewed published data does — and shows that proton therapy can significantly reduce the (radiation) dose to bone marrow, bladder and small bowel compared with the treatment UHC wanted.'” When your priority is to save a patient who otherwise will die, you opt for proton beam therapy, but when you are only interested in profit, whether the patient lives or dies is largely irrelevant. Brutal, but true.
The cost for treatment was $95,000. Without that treatment Kate would die. At 33. Fortunately, her parents instantly stepped to the plate, invaded their retirement account and wired the money to the hospital.  With the treatment that UnitedHealthcare felt would not work, Kate is now cancer free for two years and without side effects.  Not everyone has parents who can provide the $95,000 necessary to save their daughter’s life. Some parents without those resources, instead get to watch their daughter slowly die. At 33. As the summary below describes this is far from an isolated instance.
Click here to read the full report. It is extremely well written and very compelling. Share it with a friend and use it to encourage them to get involved in supporting the HSA in NM.

Kate’s Situation is Rare. Irresponsible Insurance Denials Are Not

From a report from CBS news: “A recent survey entitled “Not What the Doctor Ordered” from the Doctor-Patient Rights Project (DPRP). Health insurers denied coverage for nearly a quarter of the Americans with chronic conditions or persistent illnesses. In a third of the cases, these patients, all of whom had insurance coverage, said their conditions worsened after being rejected.”  Furthermore, survey respondents who were successful in making appeals, indicated that in 30% of the time the delay in getting approved was three months or longer.  If you are Kate, you do not have three months.

Also from the CBS report:  “As denials and interminable delays rose, about four in 10 health insurance policyholders said their opinion of their insurer had declined, according to the DPRP. Only one percent said they trusted their insurer’s judgment. The DPRP study said that insurers have, in effect, usurped the role of doctors, and so can make their own determination as to whether a treatment is medically necessary. Insurers now tell a patient what and how much treatment he or she can have, with what drugs, and for how long.” Click here to read the CBS report.  One percent!!! Even Donald Trump is more trusted than that.

How do they get away with this? The graphic at left depicts precisely how. Insurers would rather spend billions to lobby Congress and support candidates who will protect them than to pay for care that can minimize the impact of chronic conditions or, as with Kate, to save a 30 year old woman.

From an NBC News Report. A surprising number of patients have been in the middle of costly treatment for a serious disease only to have their policies canceled, sometimes even retroactively, and found themselves responsible for astronomical bills. It’s called rescission.

In a conversation with William Shernoff, the senior partner of Shernoff Bidart Darras, a Claremont, Calif.-based law firm that represents insurance policyholders, NBC found:  “It’s a secret program that if you have a serious illness … or are on costly medications, when they get the bills, they go through [your file] and look at your application … and get medical records from the last several years. And if they find an inconsistency in your application, even if it’s an honest mistake, your policy is rescinded,” says Shernoff. “It’s a very harsh punishment visited upon a lot of people.”

Shernoff mounted a class action suit against Blue Cross in California and Blue Cross was fined $1 million for rescinding 6000 policies retroactively without even reviewing the policies for justification. I might add, that $1 million is chump change for Blue Cross.

This is the ethos of capitalism: make a profit at all costs to your customer. Lie, deceive, delay, dissemble, but no matter what–make a profit. How much of a profit? Enough profit to pay CEOs obscene salaries.

It is time to begin dismantling the capitalist economic model piece by piece and one place to start is by removing health insurers from the healthcare equation. Share this post with friends, reach out to The Health Security for New Mexicans Campaign, send a check, agree to host a house party, get trained to door-knock, but we are all dependent upon our health and while we care, insurers don’t.

Another takeaway from this post relates to something reported n Tuesday’s post when I made the case for supporting MLG for governor despite her ties to gas and oil. I stated that your vote is not an affirmation of full agreement with her positions, but rather a vote to create the political environment in which you want to operate for four years. While likely requiring HEAVY pressure, MLG is far more likely to sign the Health Security Act than Steve Pearce.

In solidarity,

Paul & Roxanne

4 thoughts on “Insurers Routinely Refuse Payment on Life-Saving Treatment: NM Health Security Act Needed

    • The article referenced DSA as having endorsed the HSA campaign and I forwarded the blog to DSA leadership with their expressing their appreciation for the blog and their involvement. We plan to meet when Roxanne and I return.

  1. In a compassionate culture, it is immoral to profit from illness, injury, and accidents.

    In a capitalist system all individuals have only two functions: to produce items or services that will generate profit or to purchase items or services that will generate profit. Too often the recipient of these profits is no where close to the creation or application of the profit or service. We are all wage slaves, profit-shills for the 1%. Until we decide not to be.

    We live in an era and a country where every interaction is monitized to enrich someone. Why? When did this happen? (Hint, its part of the GOP plan since 1975) Our economy and our country has become a giant multi-level marketing game, a pyramid scheme with only very limited room at the top of the pyramid. The rest of us are just drones.

    Ultimately all pyramid schemes collapse. The next economic global collapse is already in sight — possibly as soon as 2020, according to many economic experts. This will create the opportunity too long delayed to establish an economy based on human values that serves the people, not the corprotacracy.

    Let us begin in New Mexico to create systems which serve people, not profits. There is great potential here.

  2. It is even worse than these reports indicate. Local media has been seriously distorting all of this by design. Here in New Mexico, Doctors don’t even bother to order anything, they either know it won’t be approved, or they are dissuaded by the insurers or the corporations they work for. A lot of it is income dependent. In New Mexico the wealthy simply go out of state. The Industry found that they can postpone, delay and deny most things. I know quite a few people around here who had Cancer, and decent insurance, who were postponed denied and delayed.

    The industry has been busy creating counter narratives, Mitch McConnell declared during one of those govt hearings that healthcare was expensive, because of “unnecessary Healthcare” which was the line the corporate lobbyists fed him. That is how the industry justifies deny, delay and postpone. They routinely distort facts and statistics. Pretty much every local article about any aspect of healthcare uses distorted facts and deceptive statistics. The same is true of any corporate media. Bernie was on MSN the other night, he was talked over and it was really disturbing to watch, how the subject was changed every time he mentioned healthcare. The major networks are advertising for pharma constantly.

    The Documentary “The Bleeding Edge” is out on Netflix, and industry trolls are already attacking it. No local media outlet will mention it. The industry is already misrepresenting the facts portrayed as outliers. It is pretty terrifying, the industry is Gas Lighting us all. Lujan’s Medicaid Buy In is another Gas Light. Most New Mexico Physicians can’t afford to take Medicaid, their figures are deceptive. The only places in New Mexico that take Medicaid anymore are those Low Income Clinics. They are federally funded for some things, but anything more complicated and people are SOL.

    The only information we get about local healthcare is advertising, They are cleverly deceiving us all. The Medical industry has contributed to the economic despair and decline here in Northern New Mexico. That topic is off limits in all local news. Even low income seniors have Medicare, which these “Non Profit” providers have learned to squeeze for every last cent. Every postponed diagnosis, misdiagnosis, or mistake adds up to increased profits. The local “Alternative Medicine’ community is cashing in on the distrust, deception and misinformation too.

    The local news has been actively slamming and demeaning low income people, when they don’t have anything from other mass media, they put the deceptive health information in the opinion section. There are still a few laws about healthcare marketing, which they cleverly get around by using advertising and opinion. It is way worse than we know, no news is covering the horror, desperation, despair and denial. We can only estimate the number of deaths, they are conveniently not counted by design.

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