Primary Physician Care, a privately-owned insurance company based in Charlotte, North Carolina, has now twice refused to pay for a 3-year-old’s special leukemia treatment recommended by doctors at Duke University Hospital—even after the child’s mother called the insurance company and spoke personally to the president. The child, Paxten Mitchell, suffers from a rare form of the cancer called acute lymphoblastic leukemia, or ALL.
“The fact is, my kid has leukemia, and if he doesn’t get this treatment, he will die,” Robert Mitchell said. “The way they made me feel was that they were pressuring us to take him home and let him die. We’ll try anything that has a chance of succeeding, and I will not give up fighting for it to be covered.
“Go to their Web site, and their mission statement says they treat each person with compassion,” he said. “I think that’s a bunch of hoopla.”
Paul Tate, a spokesman for Primary Physician Care, said the company is not authorized to discuss Paxten’s case.
Aw c’mon, PPC, at least say you’re taking the lives of your customers’ children very seriously or something. Don’t you know how PR works?
(Thanks to Adam!)
“Insurance won’t cover child’s critical leukemia treatment” [Asheville Citizen-Times]
RELATED
www.primaryphysiciancare.com
(Photo of Paxton Mitchell: Citizen-Times)
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@dorkins: You don’t know how right you are – small cities with two hospitals will both get an MRI machine – which raises the costs of health care – because they are competing for patients, despite the fact that they don’t need that many for the number of people being served. They also spend a lot of money on advertising.
wow this really is a tricky one, if it was my kid of course I would want to try everything possible. However insurance companies are not non-profit. They could end up paying for this experimental treatment which ends up doing nothing, and they are still out all the money. When you look at a case by case basis yes, it gets personal and for every sick person, there’s probably at least one person that loves them and wants them to live. How much more do we want to spend on insurance to cover everything? From the loved ones perspective it’s a life, from the insurance company’s perspective it’s a loss of money. I don’t know what the answer is. But as someone mentioned earlier, healthcare is not endless, there is a lifetime limit. Say they pay for this treatment, which caps out their insurance, and then 3 years later the child needs something else experimental to save his life? The insurance companies do say no sometimes. What about that St Judes hospital commercials that say they take all children regardless of the ability to pay? Couldn’t that be an alternative to going through insurance? Personally I hope they find a treatment that will cure this child, but I’m not sure it’s the insurance companies responsibility to say yes to every experimental treatment.@MissPeacock:
@vdragonmpc:
The insurance company has a fiduciary responsibility, not only to its owners/shareholders, but to its other policyholders.
If an insurer starts paying for every experimental (note: unproven) treatment out there on the advice of every physician, then these companies wouldn’t be able to pay for regular procedures for you and me.
In this specific instance, we don’t know all the facts, whether the procedure was experimental or not. So let’s reserve judgement until we do.
@misteral: in the east coast provinces i would agree… in Ontario, for sure that kid would have been treated. next time stop by Sick Kids in Toronto and take a ride up to the 8th floor and look around.
@Carencey: This is why there needs to be strong governmental regulation and rapid enforcement (ie, not through the courts while you or your kid are dying) if you’re going to use a private insurance model to fund healthcare.
The real, underlying problem is that insurance just doesn’t work very well at providing healthcare equitably to most of the population. Financing healthcare should be viewed as a shared cost to society rather than a profitable industry. Otherwise, there is too much of an economic incentive to place profits over people’s lives and over the equal delivery of care to everyone. I’ve said this before on here, but insurance works when it’s spreading the risk of low frequency, high cost events (like car wrecks, or house fires, or maybe even catastrophic health events for otherwise healthy young people). It does a worse job when the events it’s paying for are not low frequency, like with the elderly or with a chronically ill person. And unlike many other things we insure against, the cost of health insurance doesn’t really do much to change people’s behavior to reduce risk (and thus cost). Much disease is not lifestyle-oriented. You can’t choose not to get cancer.
That being said, I don’t believe insurance companies should be forced to pay for truly experimental treatments; if they are actually experimental, then that should come out of research money. A government healthcare system probably wouldn’t pay for that either. The problem comes in when the insurance companies try to define things that really are not experimental as experimental in order to avoid paying for them. They frequently do this with new treatments that are often better than older methods but with less of a track record. That’s when the government needs to step in…the insurers should probably be forced to pay for whatever the government deems non-experimental. Unfortunately, a lot of the people who advocate for private insurance solutions also are rather anti-regulation and anti-enforcement.
@se7a7n7: Universal healthcare is not the answer, unfortunately. I had that in Canada, and having experienced both systems, I would take the american in a heartbeat. As another commenter has posted, even in canada, most experimental procedures would be denied.
The problem with US healthcare is medical malpractice. Specifically the mad cycle that is perpetuated by medical malpractice.
1. Doctors, afraid of medical malpractice suits prescribe way too many tests just to cover all angles, even those he/she doesn’t believe to be true. Cause a missed diagnosis is just as bad as a wrong diagnosis.
2. Insurers pay for these myriad tests increasing their costs.
3. Insurers water down their insurance plans and/or make premiums more expensive to employers and insureds.
4. Employers pass these costs to employees.
Make no mistake, it’s the out of control litigious “lottery” system that we need to reform before we need to reform how healthcare is paid for. Once we put a cap on non-economic damages (things that can’t be quantified, like punitive), our healthcare system will start to become controlled.
@B1663R: treated yes. If an experimental procedure is involved, I doubt OHIP would pay for it.
@timsgm1418: Agreed.
From a cold-hearted business perspective: for whatever reason, the insurance company decided that they could not spend more money on this child; already over the cap, experimental treatment, etc. I’m sure that someone in a office somewhere denied the coverage for jollies. You think that the cost of healthcare is high now? What do you think it would be like if the insurance companies approved treatment for people based on emotions? WOW! As for the government health care route, I sincerely believe that the government would have stopped coverage sooner than the private insurance company. Is there a reason that people think the government would be more compassionate than any private company?
However, from a father’s perspective, I would move heaven and earth to get my kid treatment in this case, so I certainly do not blame the parents for appealing to the newspaper to try to sway the decision of the insurance company. I wish them luck.
@camille_javal: Yep, competition actually increases global costs of healthcare in many cases. But don’t try to argue that with the free market dogmatists. They believe on faith that free markets solve every problem. In reality, free markets make some things more efficient and other things more inefficient and inequitable. And in any case our healthcare system bears no resemblance to a free market.
Life is a limited resource problem.
Succint and very true.
@llcooljabe: You’re making a mistake that I see a lot and that is very easy to fall into. The fact is, there is no one cause of the out of control cost of healthcare in America. There are, in fact, many causes that need to be addressed via serious reform if we want to make healthcare affordable and equitable. Medical malpractice is one cause of spiraling costs, onerous insurance company administrative requirements are another, duplication of services and equipment caused by competition is another, the problem of providing charity care to the uninsured is another, etc.
Basically, our system is being pressured from a lot of sides at once, to the breaking point. There’s too much government regulation in some areas, and not nearly enough in others. There are frivolous and expensive lawsuits. There are abusive insurance companies, and deadbeat scamster patients. There is the fact that a large portion of the patient population in some places is on Medicare or Medicaid.
@Peeved Guy: “I’m sure that someone in a office somewhere denied the coverage for jollies.”
should read:
I’m sure that someone in a office somewhere DID NOT deny the coverage for jollies.
@Peeved Guy: Well, government at least does not have such an economic incentive to deny coverage of reasonable care. Insurance companies do – it’s called profit. So while obviously a government-run healthcare system would need to control costs by drawing lines as well, they don’t have as much reason to try to cheat and move the line backwards continually. And hopefully, if your government is functioning as a healthy democracy, it is accountable to the people ultimately. Insurance companies are accountable mostly only to their shareholders, who have wholly different interests than the people of the nation as a whole. A good government healthcare system has as its goal the provision of healthcare for all the citizens of the nation. A good private insurance company has as its goal maximization of profits…patients are merely the means to do that and a cost center to be minimized. In an ideal free market like that envisioned by starry-eyed libertarian zealots, insurance companies would be accountable to competition and would have to provide good service to their customers as a result. In the real world, insurance companies function as an oligopoly (with extensive barriers to customer mobility). Moreover, even in a functioning free market for insurance, there would be patients “left out” of the system. No for-profit insurer would want to cover people with genetic diseases, the chronically ill, or the elderly if they could identify those groups in advance and teh government didn’t force them to accept them as patients.
@dorkins: True, but what cheeses me is that they operate 8-4, you would think with a waiting list they might, oh I don’t know, extend their hours so people could get treated or something?
Anyone know where all the money actually goes? I heard from a friend who had a family member in the ICU for a week that it would have cost them over 250k for a 7 day stay if they didn’t have health insurance.
I mean, what exactly is costing so much? The drugs? Doctors? Nurses? Rent for the space and equipment? And here’s what I’ve come up with:
Nurse 24x7x7 @ $500/hr: $84000
Equipment & Space Rental 24x7x7 @ $500/hr: $84000
Drugs (say every 2 hours) 24x7x7 @ $500 a pop: $42000
Doctors (the hour or two from the 7 day stay): $40000
Total: $250,000
I don’t think nurses make $500/hr, maybe $100/hr? Equipment and space rental at $500/hr, that’s nuts! I don’t know how much drugs cost either, but from what I understand the guy was hooked up to sugar water most of the time because he was in a coma, and if it cost $500/pouch, someone is getting ripped off. As for the doctor, I don’t think they make $20,000/hr. They never stay more than a few minutes, so I assume they total maybe a couple of hours for the 7 day stay.
So then my question is, who’s pocket is the money going into? Or maybe I just don’t get it since I don’t think in dollar amounts that big.
This is sick, and it’s legal! AAAARGH! Curse you for profit healthcare!
@NickRB: Possibly and the sad thing is doctors always give the worst chance scenario, because if they are wrong its good, but if they give the best chance scenario and they are wrong, they are going to get sued.
@johnva:
MY government? Where are you posting from? Just out of curiosity.
While you make good points, I have just as many doubts of a well-functioning government run health care system as you have valid points of a free market system. While I am not a “starry-eyed libertarian zealot”, I am also not a “starry-eyed liberal” that needs to have the Nanny-State manage every aspect of my life for me. More government oversight, maybe (but that just means more laws that the government has to foist upon us). Certainly not a government run health care system, that just seems like an all around bad idea (higher wait times, a la some stories out of the UK and Canada as well as lower quality care leap to mind).
In the end, I think our system needs a serious overhaul, addressing each of the item you mentioned before, but not state run, thank you.
@tinmanx: Well, care for one patient doesn’t actually cost that much money. In healthcare, costs have become almost completely decoupled from prices. Providers raise their “list” prices in part because it’s the only way they can get reasonable reimbursement from insurers, who pay only a “negotiated” percentage of the amount billed. Then, because hospitals treat a lot of patients who can’t pay the bills they owe to the hospital (even when they have insurance, out-of-pocket expenses can be enormous), the hospitals are forced to write off a lot of bad debt. They have to make these costs up by raising prices on people who can pay for their care. Unfortunately, this then means that even more people can’t afford to pay their bills, and you get a spiraling situation that ends in out of control prices, hospitals going bankrupt, and tens of millions of people who cannot afford insurance. The basic funding model for healthcare is broken.
I know a lot of people, for some reason, find fault with every aggrieved/inconvenienced person who writes in to or is featured on the Consumerist, just because — I don’t know why. They think corporations only want to make everyone happy, or something like that.
But the people tying themselves in knots to figure out some REALLY GOOD REASON a small child should die of cancer are just completely revolting.
@Peeved Guy: I’m in the U.S. I was just pointing out that a lot of people have a dogmatic belief that free markets can solve this problem when in fact the evidence shows that they will not.
I suggest you read more about the government-run systems in various other countries before just assuming it’s a bad idea. There are many different implementations of socialized healthcare; different countries have struck different public/private balances. Many provide as good or better care than the U.S. healthcare system does, ESPECIALLY if you’re one of the people who cannot afford private health insurance. While the U.S. system does very well at providing quality care for some people, it does very poorly for others. Wait times in the U.S. can be just as bad as in countries with socialized care, and our system is very cost-inefficient (with huge administrative overhead and a lot of people taking profit out of the system in various layers).
We MUST have at least some government-run healthcare or health insurance for the people the for-profit insurers do not want to cover (like the elderly, the poor, and those with genetic diseases). But that just drives up the cost to taxpayers of the government system since it just allows the insurers to take all of the profitable healthy young people and dump all the expensive people on the government.
@NickRB:
MAy you get a life ending sickness and then have your insurnce company tell you, “Sorry, we will no longer pay for your treatments.” MAybe then you’ll understand that it shouldn’t matter, they are to provide a service you are paying for.
@johnva: OK. I think we are in agreement, believe it or not.
While you cite examples of some superlative government-run health care in other countries, I would wager you could find just as many horror stories.
I like your idea of government provided health insurance for the under-insured. I have no problem with that, but when you start talking about some of the proposed solutions that I have been hearing about (mandatory enrollment, taxing the crap outta me to pay for “universal” insurance, etc.), I get chills down my spine.
In reality, this problem is so massive and complicated that no one solution will be the ultimate cure (no pun intended), there really needs to be a flexible solution. Unfortunately, I’ve not really heard any politician state they have one, and if they did, I wouldn’t believe them…
From the article itself I think this is the real reason
Dr. Douglas Scothorn, a pediatric hematologist-oncologist who is caring for Paxten, said the chemotherapy regimen is unusual for leukemia, but all of the five drugs in the mix are common chemotherapy drugs, and all are approved for use in children.
Basically the doctors are doing an unproven medical treatment on him because regular treatments are not working. So I believe the logic here would be that the insurance company is not underwriting a clinical trial for a drug cocktail to be used in pediatric chemotherapy. Basically the child is under an experimental drug treatment, which no insurance company will cover because it opens them up to liability for essentially ‘approving’ the treatment.
Why are we even buying health insurance these days when scums like PPC don’t even pay up for essential care services?
Not all “unapproved” treatments are invalid. But people complain about the high cost of medical care, and then don’t realize that something has to give. There are cancer drugs that keep patients alive for a few more months, but at a cost of, say, $18,000 a month. Okay, let’s preserve all life as long as possible! If that’s your take on health care, please don’t complain about high premiums. Personally, I have no intention of being a costly turnip in a bed, and if that comes to pass, I will either kill myself or, if the law permits, arrange for somebody to do it for me. (Dr. Kevorkian is a hero.)
Sorry – my comments don’t seem to be going through. This one never showed up.
Just because a treatment hasn’t gone through the approval process doesn’t mean it won’t work.
But, people complain about the high cost of medical care, and then don’t realize that something has to give. There are cancer drugs that keep patients alive for a few more months, but at a cost of, say, $18,000 a month. Okay, let’s preserve all life as long as possible! If that’s your take on health care, please don’t complain about high premiums. Personally, I have no intention of being a costly turnip in a bed, and if that comes to pass, I will either kill myself or, if the law permits, arrange for somebody to do it for me.
@tinmanx:
I was told that insurance companies usually have much better negotiated rates (usually about 1/3 the cost). So 250k goes down to ~75-85k. It is sort of like bill padding. If you can afford the 250k, you pay it. If not, most hospitals will negotiate with you both payment plan options and overall cost depending on your financial situation if you do not have insurance. For the hospital, it is better than dealing with having to cover it all because the patient declares bankruptcy.
@Amy Alkon: There’s a huge difference between assisted suicide and refusing treatment. Huge.
BTW, if you don’t want to artificially extend your life, it’s best to put that in a living will, so your family is not faced with a Schiavo like dilemma, God forbid.
Lately, it is becoming clear that patients who are dying (especially when it comes to cancer) want in on clinical trials. Current laws and rules surrounding clinical trials don’t always let them. Some kind of solution needs to be found for this, to let that wall down.
But I didn’t realize that a chemo drug protocol could even fall under this heading.
Impossible to intelligently analyze this case without knowing the terms of the insurance policy and the stated basis for the denial. This may fall into the category of experimental treatment, which usually isn’t covered. Health insurers are a business, not a charity. They shouldn’t be vilified any more than the hospital is for charging for the treatment.
@NickRB: Yes, let us allow people to die so your rates don’t go up.
Dont you just love how some health companys can pretty much hold a perverbial gun to the head of its patients and pull the trigger when costs get too high?
Wait a second isnt the human race supposed to be intelligent?
This Insurance Company: Greedy MFs
Insurance companies will classify a lot of treatment options as “experimental” even though they’re really not. Hubby had an eye procedure a couple years ago which can’t technically be approved by the FDA, because large enough studies haven’t been done. Why not? Because the incidence of his eye condition is so low that there aren’t enough people to actually do the studies. BUT, the FDA did give the procedure what’s called a “humanitarian exemption.” This means they acknowledge it can’t be approved under normal rules but that it’s still safe and effective as far as they’ve seen. (After an initial denial, we managed to get the insurance company to pay for the procedure after an appeal letter.)
The point being, a lot of these types of procedures are still classified as experimental by the insurance companies, when it’s really because the condition is too rare. It sounds like this kid’s leukemia is a particularly rare type, so I wouldn’t be surprised if something similar is going on.
Read the liked article: “but the company that administers the city’s self-insurance plan refused to pay for it.”
If it’s self-insurance the city can tell the insurance company to pay…I wonder that hasn’t happened?
Problem is the child has a RARE form of leukemia – Insurance companies are set up to auto deny lots of treatment for rare diseases and bank on people not fighting it. The dilemma with the “experimental” treatment is that due to the RARE nature of the disease, there has surely not been enough research to prove effectiveness – nature of the beast, but insurance companies need to accept this and be reasonable, instead of using this as a reason to deny, deny, deny…..
I am super sick of insurance companies trying to make my medical decisions instead of my physicians.
Just another interesting figure to throw out there: The costs of administering health insurance in America adds 30-45% to the cost of health care. Just took a course in U.S. Healthcare, quite enlightening to hear the story from actual doctors and insurance co’s. BOTH are to blame. Can’t forget about the trial attorneys either, they’ve certainly caused more of a mess than helped.
@tinmanx:
My hubby, a doctor, is amazed that most of the $$$ goes to the hospital – less than you would think goes to the physician etc….
the bottom line in all this is a human life…i read a lot of rationalization in the above comments….it still boils down to a life, not dollars….dollars can be recovered, the life can’t….and as i understand, medical people are supposed to fight for life to the last breath…..swo fight, worry abolut the money later….
.
@johnva: With the MRIs and CT Scanners, if you have them, you have to use them. So in past situations, when a standard x-ray has worked, now CT Scans are ordered, driving up the cost of care.
I am pretty sick of the CYA excuse for over use of incredibly expensive services and machines. It’s not CYA, it’s padding the bill.
Like any other situation nobody pays any attention until somebody dies. In the case of HMOs, it will probably take the killing of an HMO’s CEO by a “John Q. Public” movie copycat before anyone does anything. The politicians sure as hell aren’t doing anything despite the endless number of cases of people being dumped out of hospitals and left to die.
No, I am not advocating violence, explicitly, subtly or otherwise. I’m saying that it’s inevitable that somebody is going to go overboard because legal means aren’t working.
The leukemia that this child has, Acute Lymphoblastic leukemia is the commonest form of the disease occurring in children. It is curable and it is criminal that an insurer refuses coverage.
http://www.medicynic.com
It’s amazing how quickly everyone has an expert opinion on this.
Cycledoc is right, ALL is a very common form of childhood leukemia. Unless it’s a clinical trial there should be no reason to deny the coverage. In fact, decent insurance companies will even cover clinical trials.
One of the reasons hospital/doctor bills are so high is because insurance companies argue these bills down. It’s like a very large game of back market haggling. Another reason, at least with cancer patients, is that many patients never make the payments to the hospitals because they die.
The hospital is trying to recoup money lost through insurance companies, and other avenues by billing extremely high prices and then taking what they can get.
We can argue about this all day, but think about this for a second:
One month of induction chemotherapy for Leukemia cost between $150,000-$200,000. If you’re lucky, you have health insurance and you’ve got some coverage for this. Now your coverage might be 100% or might be less, but all plans have caps and you’re coverage will run out eventually.
I’m 23 years old and my fiancee was diagnoised with Acute Myeloid Leukemia on January 3rd of this year. It’s similar to ALL that was mentioned in the story.
Her insurance is 80/20 coverage. Her total treatment costs, including a bone marrow transplant will reach into the millions of dollars. If we’re very lucky, she will survive a bone marrow transplant and we’ll be in dept a few hundred thousand dollars. Enough dept for a few graduate degrees and a very nice house.
We’ll be financially destroyed by 25.
But if she lives, it doesn’t matter.
Which is probably why you don’t hear so many families of cancer patients vociferously calling for healthcare reform.
Just having their loved one survive leaves them so thankful.
I am quite serious when I say that this would not happen in Canada.
/Damn our universal health care.
//Its much better to put profit ahead of a kids life.
///American health care sucks and blows at the same time
This is not the insurance companies fault. Self insured means that the city decides what it covers, and has final say on what it pays out — Self Insured means the insurance company charges the city an administrative fee to process the claims, and provide access to it’s network of providers, as well as provide initial decisions, but final say is always reserved for the employer who purchases the service of the insurance company… or the city.
I think it is important to understand the particular issues of this boy before we can intelligently discuss whether his insurance company has done something wrong
While ALL is the most common childhood cancer, this boy’s disease has an unusually low number of chromosomes (hypodiploid). This in and of itself indicates a poorer prognosis, with a overall survival of about 50% at 8 years.
In the largest study of these particular patients, “Outcome of treatment in children with hypodiploid acute lymphoblastic leukemia” (Blood, 15 August 2007, Vol. 110, No. 4, pp. 1112-1115.), the few patients who actually received bone marrow transplant saw no difference in event-free survival or overall survival.
The experimental treatment in question (a Children’s Oncology Group protocol) calls for a pretty rough treatment regimen AFTER induction. The chemo agents in question are cytoxan, high-dose cytosine arabinoside, VP-16, and high-dose methotrexate. This combo is basically intented to knock out his bone marrow to allow for a transplant.
In the article, his doctor says he failed induction. Before he will even be eligible for BMT, they must induce remission. Until we know what actual regimen his doctor is utilizing, we can’t really say whether the insurance company has done anything unusual. In my experience, neither an American insurance company, nor the Canadian or British Health Services would cover non-traditional chemo regimens.
Paying for insurance is institutionalized gambling. I used to nearly bankrupt myself every month, paying Kaiser nearly $500 a month for services I rarely used (I’m self-employed, so no health benefits for me), all because I previously had a health condition I feared would return. The sum total of what I paid into my “coverage” for five years, before switching to a temporary plan that cushions the blow for a few years? Roughly $28,000.
The value I got out of paying this amount? Give or take: probably 10-15 doctor visits, maybe two pairs of eyeglasses (which I still had to pay for, in addition to my monthly membership fees), a single prescription (for a drug which caused me temporary kidney damage and that it turned out I did not really need). Wow, THAT was money well spent.
I have grave concerns about the fact that every time I leave my local Kaiser Hospital, I am shaking off the very real sense that I am considerably smarter than the medical staff therein. I draw cartoons for a living, and I dropped out of college. Anyone see a serious flaw with the math, here?
My younger brother was born with a birth defect in 1976 — on that day, the doctors t the hospital bluntly told my parents not to “get attached”, then tastefully inquired as to whether they would like for the nurses to feed their newborn baby or not. My brother is alive and well today, coming up on middle age, no thanks to the asses that were working that day. The medical industry didn’t know what the hell it was talking about, and they had all the bedside tact of Doctor Mengele. Things have hardly improved in the thirty-one years since.
FUCK the medical industry, FUCK the surgical industry, and FUCK the pharmaceutical industry.
There is no such thing as a “good” medical insurance company; the truth is, they’re only interested in surgically removing your money from the bank.
Hippocratic Oath my ass.
@myasir: Huh? I’m not sure what article you were reading…
“But then his doctors heard from doctors at Duke University Medical Center about a treatment protocol that has proved effective in cases like Paxten’s. The Mitchells agreed to go ahead with it, but the company that administers the city’s self-insurance plan refused to pay for it.”
“Proved effective” is hardly the same thing as “experimental”. I’d go so far as to say they are opposites.