Judge rips insurance company for "immoral, barbaric" cancer denials

A CNN news report posted today of interest to us for a number of reasons.

A federal judge is blasting UnitedHealthcare for "immoral and barbaric" (his words) denial of treatment for cancer patients.

It is especially interesting to us because the judge in the case "...made the comments in recusing himself from hearing a class action lawsuit because of his own (prostate) cancer battle," and the case "... was brought by a prostate cancer survivor."

At issue is the insurance company's refusal to pay for proton beam treatment, on the grounds that it is still "experimental."

"In his recusal, (Judge) Scola cited his own battle with prostate cancer and how he consulted with top medical experts around the country about treatment options..." becoming convinced that proton beam treatment was "... a wise course of action." He also cited the case of a "friend" who was charged $150,000 by UnitedHealthcare for proton beam treatment at MD Anderson, but the insurance company eventually agreed to pay when faced with threat of litigation.

The report then goes on to discuss the merits of each side of the argument, such as effectiveness of proton beam, as well as its higher cost. The tone of the rest of the report is that proton beam is still controversial, but it also cites reasons why UnitedHealthcare did decide to cover it.

Yes, an interesting report for a number of reasons.

https://www.cnn.com/2019/05/16/health/judge-proton-beam-therapy-recusal-unitedhealthcare/index.html

It is not clear what insurance he had at age 70, I normally would assume it was Medicare or Medicare Advantage plan but that would have been more cut and dry since PBT has been approved by Medicare for a while to the best of my knowledge. I suppose it is possible he had a private plan if he was still working thus a different set of issues.

At the end of the day, the Hopkins doctor said what my RO said, the current data does not support PBT being better then IMRT for prostate cancer and he came from Mayo where they have had a proton machine for a while. It is probably a good idea that the judge recuse himself since he would tend to judge based on his opinion and not the facts of this specific case and current understanding. The experts will always argue and disagree about these treatments and it is usually up to a jury to sort it out.

That being said, I do not like insurance companies for the most part and would like to strangle whoever comes up with some of the rulings and policies I have encountered over the years.

I don’t often side with insurance companies, but if Proton is no more effective than standard RT, and it costs significantly more, I think the insurance company has a legitimate dog in this fight.

Proton beam therapy for prostate cancer has been reduced from 44 to only 5 sessions in a clinical trial at several large institutions. This is their SBRT emulation protocol, and I have seen posts from several men in those trials who were very satisfied with their experience. Those institutions may start treating non-trial men by the end of 2019.

Certainly, you can’t justify charging the same for 5 sessions as for 44, so that may bring the remaining insurance holdouts to endorse PBT.

While these kinds of remarks make news--and they are exciting headlines--they do beg the question: do we really want costs to go down? It's one thing, IMO, if the only potential treatment out there is denied because it costs too much--and quite another if there is a lower cost equivalent treatment with similar outcomes.

There are a lot of places one can put ire about insurance companies--but this one may not be the ideal test case.

I could see that if in fact the results of proton beam are no better than IMRT, then the insurance company has a right to turn down PBT. What about side effects?

After my first (negative) Biopsy, my URO wanted an MRI. My insurance co denied coverage, saying they’d only cover it AFTER I was diagnosed with PC. How obtuse.
I asked the Dr if he thought it was really critical, saying if so, I’d pay it out of pocket. He said no, justvretest PSA in 3 months instead of 6. I wish I’d told him I’m paying for it, rather than asked him. It would have resulted in a repeat biopsy a year earlier than when I was diagnosed.

Thank you xxxxInsurance. 😡

Ken,

Regarding the side effects of PBT versus IMRT/IGRT they are similar and no advantage to either treatment. In the old days before IMRT the PBT had some advantage due to the thinner beam possible, but that advantage was negated some 20 years ago with the advent of IMRT.

Regarding the insurance, we rarely have reports here that insurance or Medicare is not covering a mainstream treatment. For our friends in other countries, we do see more control on their choices and often the timing of and availability of treatments. A few years ago there were some issues with a few companies and SBRT, but nothing has been stated for some time. The main ones now have to do with PBT, but that is fine because it isn't better than IMRT, so no loss. And then certain scans and their timing as Ken reported. That issue isn't limited to PCa, but to most every condition.

The insurance company, Medicare, Medicaid VA, any third party payor is essentially going to approach this in much the same way as any of us would if we were completely self paying. We want to know the procedure is necessary and is the best cost available. If not necessary, then we would generally not incur the cost and risk of the procedure. If considered too expensive we would look for other providers and/or negotiate the price. After all we do this with most every expenditure we make, particularly the big ticket items. Most of us have been using a third party payor all our lives and while we are premium, deductible and co-pay price sensitive, we care not what the cost is to the payor. With public payors it is all about cost control or taxes must be raised or treatments rationed and our elected officials want neither because then we vote them out. With insurance companies, self insured employee benefits plans and unions it is all about cost control as there is clearly a profit and solvency motive. With self payors it is all about cost avoidance first and then control as we generally have other uses for our limited resources. As bad as the insurance companies and other third party payors are at times, think what it would be without them and we were all self paying. We would probably deny treatments and procedures for ourselves far more than the payors actually do.

Jack, you make good points. And yes, Medicare needs to operate within their budget, and so far, from what I’ve seen, they do a pretty good job balancing that with the need for good patient care.

Private insurance companies though are different. While everything you said is correct, I believe there are situations, some of them critical where the profit motive rules. We’ve all seen the news bites about the little girl with a brain tumor or the man with a rare form of blood cancer who is denied a cutting edge, but FDA approved treatment, treatment because it’s chances of working are less than ideal, even though it’s the only chance Patient has to survive. I’ve also read about The insurance companies hiring retired doctors, to make decisions on approvals and then marching orders are to minimize costs.

Not saying that insurance companies are screwing with us on every decision but it does happen and I think it happens more often than we would like to believe. JMHO.

Jack, and the last serious attempt to deal with the medicare insolvency issue--which really boils down to the alarming statistic that a huge percentage of a person's lifetime medical costs are incurred in the last few months of life--where maintaining a breathing body is seen as paramount, no matter the cost--was shouted down as "death panels" and "pulling the plug on granny".

Until we are willing, as a society, to get real about end of life care, and last ditch medical interventions where there is little or no chance of success (whatever THAT means in this context), then the insanity will continue. It's alarming (and I witnessed it in my own life 2 years ago, with my mother) how willing we are to create suffering for the elderly in the name of saving their life.

Somebody said...
Until we are willing, as a society, to get real about end of life care, and last ditch medical interventions where there is little or no chance of success (whatever THAT means in this context), then the insanity will continue. It's alarming (and I witnessed it in my own life 2 years ago, with my mother) how willing we are to create suffering for the elderly in the name of saving their life.

maybe getting religion out of government would help (rhetorical question)?