Way to sensationalize the topic.

Sorry to hear about your brother... good luck.

OMG! When will these companies learn? Someone needs to reach out and touch PacifiCare where it really hurts. My heart is breaking for Nick and his family. Whether he ends up getting the insurance coverage or not, this company is criminal for what they are putting Nick and his loved ones through.

OMg is that right they have 12 BILLION DOLLARS? and they cant pay for this?

This makes me ill. My younger brother is a cancer survivor after radiation and a bone marrow transplant (not chemo)saved his life. Give them hell - everyone deserves a fair shot.

Hmm... shouldn't the doctors perform the procedure and then worry about billing later?

Thanks for posting this story! This is much more important than receipt checking, a typo at Wal-Mart, or a snotty cashier!

Yeah. Why don't the doctors just perform the procedure no matter what? They should donate their time and the materials for it.

I like how the executives of this company are making some ridiculous 8 figure number.

I agree that our healthcare system sucks big time, but I think the hospitals and doctors are also part of the problem. Hospitals bring in millions and doctors also make millions, yet they can't donate their time / equipment to save someones life every now and then?

Hopefully the protest and media will make a difference in this case.

I can't wait until we socialize medicine, then as a society we can come together and decide just how much a human life is worth and settle that debate once and for all.

The whole billing thing is odd though - usually, the billing concerns comes after the procedure, not before.

I couldn't find this in the story: what is PacificCare's stated reason for denying care? Did I miss it somewhere?

It's too bad this didn't get posted earlier; less than an hour's notice isn't much time to get to a protest. I'm actually close enough that I might have been able to make it (I just moved here recently and google mapped the address out of curiosity and realized it was about 8 miles away) if I'd known far enough in advance to schedule my day around it. My heart's with the Nick and his family, even if I can't physically be there.

What was the Denzel Washington movie where he held an operating room hostage because health insurance wouldn't cover his son's heart surgery? John Q?

I'm surprised the same crap hasn't happened in real life.

OK, here we go again.

1. I certainly feel sorry for this guy.
2. Every health care system has to have someone who decides "given the chance of success, the benefits of success, and the cost, we're not going to do this procedure."
3. We need to decide who the entity in #2 is. In single-payer national systems, it's a gov't official who makes the call. In our system, that responsibility is held by private health care companies. In any case, it has to be SOMEBODY who says "no, we're not going to do this."

#2 and #3 suck, but until we find a system where health care fairies deliver medical services to everyone for no cost at all, the call has to be made.

The insurance company is actually holding this guy hostage in California just to kill him? It's too bad they're being held against their will. Because then they could just go to Kansas City and try to pay for it themselves.

Instead of a demonstration, how about a fundraiser to pay for his procedure? It's clear that this company has no interest in paying it.

But I sincerely hope he can be cured one way or another. My prayers are with him and the family.

Did a bit of research on this procedure and it sounds like managed care companies don't know enough about it to feel comfortable approving it. Plus the cost of the tx tends to be anywhere from 20 to 60 thousand dollars--this for a device that costs several million to buy. If there is a chance that it could be effective, and it has been for others, why no approve it? As an aside it does beg the question as to why the tx is so expensive when a hospital could make their initial investment back in no time.

@failurate: From a moral standpoint, perhaps... but the way a lot of PPOs and HMOs work is that unless expensive medical procedures are pre-authorised, the insurance companies reserve the right to deny coverage.

It makes me angry that this isn't even a little bit surprising. Health Care Providers are the most unconscienably evil companies in the US.

@zrikz:
The doctors may not be blameless, but the they are getting screwed by the insurance companies too. Most doctors don't make millions, in fact an average salary for a pediatrician is maybe 125k. I am currently in med school and even with a partial scholarship am going to be 160k in the hole when I am done. And thanks to congress I won't be able to defer my loans anymore when I am a resident for 3-7 years (making maybe 40-50k that whole time). I am going into medicine because I want to help people, but I am not going to ruin myself financially because of the insurance companies/our healthcare system sucks. 8 years of college plus at least 3-7 more years of training all while being poor sucks.

To everyone else, next time you have to take your sick kid to the doctor, especially if its a young physician, remember they are getting the short end of the stick too. Until a nationalized healthcare plan (including goverment paid for schooling) is in place this type of situation is only going to happen more frequently. There is already a shortage of doctors (and only getting worse). Blame the executives making money off other people's misery, but don't blame the doctors.

@Sasquatch: There will be little to no difference between what we have now (companies making the call) and what a single-payer/universal system will be (the government accountant making the call). Ultimately, as it has been stated before, someone is going to put a value on a human life (relative to the cost of the procedure, the chance of survival and other factors) and we'll have to live with it.

What method would be appropriate? Should we handle this using an actuarial table? How much is this person going to earn (discounted of course for time-value of money) set against chance of death, etc. If its the government, wouldn't they then factor in the amount of taxes that he'll be paying against the cost of the procedure? Again, you can't get away from the financial aspects of this decision... unless the hospital and doctors want to do this pro bono.

But I doubt they want to do that. Doesn't that make them just as evil?

"PacifiCare was recently fined $3.5 million by the state of California for systematic mishandling of at least 133,000 claims like Nick's. The company is facing up to $1.3 billion in addition penalties, for illegally denying care, and a Department of Managed Health Care investigation found that the corporation wrongly denied claims in 30 percent of its HMO cases in 2006-7. In 2005, PacifiCare was taken over by the nation's largest health insurer, UnitedHealth, which is expected to grow its profits 13 percent in 2007-8, according to recent reports."

[www.calnurses.org]

Hmmmm Yet another person denied a needed medical procedure from UHC. Im so surprised give those scumbags a year or two and aspirin will be 'experimental' and seeing a doctor for any reason will require pre-approval from an outsourced medical 'authorization facility' in a third world country.

I wouldnt shed a tear if I saw these executives getting picked off one by one. Heck I may even have a drink in celebration. There is no excuse for these companies to have such lopsided compensation for ceos and stockholders while the PAYERS get nothing in benefits.

Its time for them to be broken up, prosecuted for fraud, jailed and shut down. That company does NOT provide Health Care Benefits to members as they are supposed to.

Tux and JustaGuy have it right.

#2 and #3 suck, but until we find a system where health care fairies deliver medical services to everyone for no cost at all, the call has to be made.

...unless the hospital and doctors want to do this pro bono. But I doubt they want to do that. Doesn't that make them just as evil?

If every procedure was paid for every patient, regardless of the cost and the chance for success, we'd all be paying a large multiple of what we are paying for our own health care.

If it is nationalized, someone still has to pay for it, and it'll still be you.

Someone suggested instead of protesting, start a collection. That's a great idea, if only for the fact that YOU get to start deciding if it's worth sending YOUR money for an expensive procedure that has little chance of having any prolonged benefit.

I do feel for anyone going through this.

But the saddest part of all of these stories is that we have the nerve to complain that incredible life-saving procedures are available to us, but we can't pay.

What a miserable country we live in where people have performed fantastic medical advances, but were too dense to make it affordable by everybody.

@vdragonmpc: Maybe you missed something in the stupidly short notes by the blog's author: "Nick has been unresponsive to chemo." If you read the doctor's letter, they also state that he had been given several other forms of treatment, all of which did nothing to prevent the tumor's growth.

Like it or not, there comes a point at which risk/cost v reward must become a factor. Sure, United could approve any and all treatments for Nick, spending a fortune to do it, but then everyone else would ask the same thing, and then they would be in bankruptcy.

I find it so ironic that people bemoan the insurance companies making a profit, C-level officers making money, shareholders making money, but they have no problem with the doctors, hospitals, etc making money. Would the family be willing to sell their house and other possessions and saddle themselves with debt to pay for the treatment? If they did that, I'm sure there are people/organizations that would donate to reduce the cost and help them survive.

But, oh my, a universal, government-run system would make EVERYTHING better. Oh dear God help us all.

@Tux the Penguin: That's the kind of good thing about the way it is now, competition means that at some point some company will make a lot more friendly choices on this stuff. It may cost us more, but when it is one entity for everyone...what do you do about their decisions? go somewhere else, threaten them with this kind of publicity? that won't work with the gov.

I'm not saying that any protesting/show of support is going to help this guy's brother for sure, but it could help others in the long run.

Who has read the Doctor's letter? It does not say this treatment will cure anything, but allow them to provide palliative support, start to kill the tumor and allow opportunities for OTHER treatments.

In other words, it seems that this treatment - if succesful - will keep the young man alive for a while longer, make him more comfortable, all in the hope that they will be able to provide some sort of other future treatments.

United Healthcare may be a vile company, but paying an insurance premium cannot be construed as carte blanche to any treatment, at any cost, regardless of expected outcome. Regardless of whether it's an insurance company or our government making the decisions healthcare can never be unlimited. Others have already made this case well.

Of course many people happily buy $500,000 houses and accept 30 years of debt. Is the family not willing to do the same to help extend Nick's life?

Since the procedure has NOT been done, no claim can be denied, no claim has been made, as there is no bill for services. Likely, the treatment plan was submitted (HMO preapproval) and was denied. The family can proceed with treatment, and when the bill comes, then try to fight. Of course they can just declare bankruptcy like many stuck with huge medical bills do. This simply shifts the costs back to the hospitals and doctors with eventually trickle's back to everyone.

I would strongly encourage this family (if they haven't already) to sit down with the hospital's patient ombudsman, learn about the expected costs of the treatment plan, available discounts, charity & forgiveness programs and payment plans. Start a fund to accept donations, start holding fund raisers, cross your fingers and forge ahead.

Having national 'guaranteed' healthcare is not the same as unlimited. This problem is not going to go away and the sooner a national, reasoned dialogue can be started, the better.

Now - all that being said, yes my heart breaks for this family. I like most people, have had cancer and other illnesses impact those closest to me and I will join others in prayer for a succeful outcome.

Not to defend PacifiCare here, but "murder" is a bit hyperbolic.

If the procedure costs $100,000 and has a 2% chance of success, should they pay for it? What if it costs $1,000,000 and has a 0.2% chance of success? Where is the line?

Absent these details, I think it's premature for readers to pass judgment.

First of all I believe that the person is not being murdered by UHC but is instead dying of cancer.

It sounds like he was treated in the standard way and didn't respond, in fact in the linked letter he got worse.

How much is the surgery in the US? How about other countries? Have a fund raiser and sue for the money after he survives.

I understand how hard it is to watch loved ones suffer. It's important to make his life as comfortable as possible. Consider medical care in other countries. If you really think that this will work try to haggle with the hospital. They have a lot of room to negotiate when it comes to billing and payment.

Can you pay for most of the surgery and have the insurance cover hospital care and bedrest? Can the surgeon justify splitting the operation into several procedures with some that are covered?

Good luck. Don't spend so much time fighting insurance that you forget to enjoy life. Don't wait until he is bedridden to spend serious time with your loved one

doctors also make millions, yet they can't donate their time / equipment to save someones life every now and then?

Um, what doctor do you know makes a cool mill a year? All the pediatricians I know make 90k or so. Also, hospitals are out donating their time, ever go to an ER on a Saturday night? How many of those cases do you think they get paid for? 50%, 30%, at my local tier 1 trauma center it's closer to 9%.

Finally while I suppose insurance cos aren't ideal what makes anyone think that the outcome in the UK would have been better where survivability for cancer over 5 years is lower than it is here (Britain's survival rates are on par with east European countries such as Poland and Slovenia). [tinyurl.com]

You can spend as much as you want on health care, the entire GDP and people will still die, the money won't be enough because there will always be a new test, a new treatment, SOMETHING experimental. I don't know the particulars of this case but I'm reminded of the recent Michael Moore movie which showed a grieving woman and pictures of her dead husband who died (I believe of liver cancer) she complained that the evil insurance company wouldn't pay for a bone-marrow transplant. Which is all very well and good -- except that isn't a treatment for liver cancer. Truth is, there isn't one, pretty much a death sentence at this point, maybe that will change in the future.

This is why I think nationalized health care will be a disaster in the US. Americans aren't going to be OK with being told it just isn't worth it to save their 98 year old granny with failing kidneys. You have to draw the line somewhere, people are going to want that line to be drawn "somewhere else."

1. good
2. efficient
3. cheap

Pick two.

@Michael Belisle: The insurance companies are not capable of denying care they are, however capable of denying coverage. They are not saying that he cannot have the procedure, they are saying that they won't pay for it. I am not saying that they are right, but if he needs the procedure that badly, why isn't the family just going through with it and suing the insurance company once he gets better?

Are people really this clueless? These people are being denied because it CUTS INTO PROFITS. Asking someone to DIE to "take one for the team" is frankly sub-human. I really do think that UHC can make a little less for their shareholders and CEO's this year and give this guy the medical chance he needs. That is what you call holding up your end of the bargain under the contract where UHC agreed to provide medical care in return for premium payments.

The problem with the current health care system is that we have a middle man whose entire business plan revolves around denying as much care as possible so they can pocket as much money as possible.

I am so tired of the scare tactics that national health insurance is going to be more oppressive than the scam private carriers are currently running. My friend on Medicare has better coverage than I do and I am on one of the better Blue Cross plans in the country.

Terminal illness is a reality. It is sad, and it is not nearly as uncommon as we would like. Wanting to go to every possible extreme to save a loved one is natural, but there is a point past which there is no reason to continue. That may be where the medical professionals are on this case, and it is definitely where the insurance company is. Perhaps the family needs to deal with the reality of losing him rather than fighting for something that, ultimately, won't matter.

Please note, however: The insurance company isn't killing him, they aren't even saying he can't have the treatment. All they are saying is that they will not cover it. The family is free to make whatever financial arrangements are necessary in order to have the procedure done. That is a great deal of expense, I am sure, and if it is due to the insurance company dodging a responsibility, sue them to recover the expenses. We don't need the melodrama of claiming the company's spreadsheet is killing him. Insurance companies do plenty of evil without making more up.

@burgundyyears: "I can't wait until we socialize medicine, then as a society we can come together and decide just how much a human life is worth and settle that debate once and for all."

yes, because it works so well in Canada. [www.americanthinker.com]

where will we go if under a socialized healthcare system that we arent able to get the care we need?

you DO realize that this situation only means that their insurance wont PAY for the procedure, but they are still free to get it done on their own dime? but in a socialized healthcare system, this situation wouldnt be about payment, it would be about just doing the procedure AT ALL.

The patient above is certainly in my prayers....

However...to create a balanced discussion what are the odds of survival for the mentioned treatment and what is the cost?

@bohemian: Would you be willing to pony up some of your hard-earned cash to pay for his procedure? Start a charity/foundation/whatever and begin working to cover those who are denied coverage. Then see how much money it would take to do just that.

But lets simplify all of this: As the insurance company, how much of that are you willing to pay to give him a 100% chance at life? What about 50%? 10%? 1%? Those are the decisions that you are bashing the insurance companies for. And, like it or not, the government will do the same thing.

But lets make this even more simple: remove the insurance companies. How much are you willing to pay out for those same chances above? Are you willing to sell everything, house, cars, boats, empty all savings and retirement funds, borrow as much as you can while maxing out credit cards for those chances?

Those are the hard questions that people don't want to think about. Most people don't have a problem calling for someone else to pay for something. But are YOU willing to pay for it. If so, then as I said before, start the "Foundation to Cover the Uncovered."

What the fuck is wrong with you all?

Way to use someone else's terrible life crisis to serve as a prime example for your political thoughts/agendas.

Oh Canada!

This is a hint that if the kid marries a canadian (depending on province, with parental consent, methinks this can be age 16 or higher for legal marriage - NOT SURE ON THIS!) then he can swoop into a Canadian hospital and have it fixed semi-pronto! I think there is a website somewhere where canadians auction themselves for marriage to US citizens (with a fun pre-nup) so they can get healthcare, then divorce and head back down. If not, i've got to create one...

Something that a lot of people seem to overlook in the analysis is that while it's true that a government official would be making the call in a state-managed system, one significant difference would be that the government should be looking to maximize public health, and not shareholder profit. Insurance companies have no interest in providing the best health care possible, rather to simply generate the greatest revenue possible (while not being burned at the stake by irate mobs for denying coverage). The government (in theory) should be willing to give up "profit" for "greater coverage."

@JustAGuy2: It does not have to be the government that decides, it can be doctors that decide in a single payer system. Its easy to assume all the negatives when it works in other countries by delivery better health care at a much lower cost?

First and foremost, I want to say that my heart goes out to this family.

Its just another reason that I fear this summer. We will be switching to Pacificare (employer insurance change) and I suffer from chronic pain. Cigna, which should be up there with the crappiest insurance companies, is even smart enough to know that a $2k ER bill is more expensive than fully (or partially) paying the $125 a month for my meds. Pacificare has already stated that they would NOT in any way, shape, or form-be paying ANYTHING toward my monthly meds.

Nothing in comparison to cancer, I realize this... but it just goes to show how unreasonable they are about $125 - let alone whatever this poor child needs.

Pathetic

@Tux the Penguin: Find me a hospital in the US which is turning an honest profit. The truth is that most hospitals are barely staying afloat at this point. We've seen a few hospitals shut down various departments and some entire hospitals even close in Florida. I'm not going to say hospitals and doctors are innocent bystanders, as the problem is multi-faceted.

The balance of trial attorneys, insurance companies, doctors, and hospitals has become terribly unbalanced. Doctors are ordering excessive tests as part of "defensive medicine", just in case they happen to get sued. Doctors and hospitals also get reimbursed by insurance to cover procedures related to their own screw-ups (nonsocomial infections anyone?) I've also seen very few doctors who actually know what the hell they're doing. I shouldn't have to go to 5 different doctors to get a correct dx.

Insurance. 30-50% of the costs of healthcare are due to paperwork and insurance. It costs money to employ people to look at paperwork and deny your claim.

Then add in the trial attorneys who will sue an OB/GYN because the baby from an alcoholic crack whore dies 3 days after birth. Entirely the doctor's fault, right? Bad outcomes DO NOT = malpractice, despite what the current vultures think. Sure, it's profitable, but at the expense of everyone else. When ER docs are having to carry malpractice insurance that costs $250k/year, don't be surprised when your local hospital's ER suddenly shuts down.

Then there's the cold, hard truth about resources. There are only so many dollars to go around. In a socialized single-payer system, there are only so many dollars available to share for the WHOLE system. That's it. Ultimately, there IS a price on human life. It's unavoidable. We could spend money on USDA & local health inspectors to make sure our food never gets us sick....but that costs money. We could make our cars and roads much safer....but that costs money. We could give our children a first-rate education....but that costs money. We could spend $5M to save one patient's life, at the exepnse of basic health care for 50-250 others. If people are willing to place a high enough value on life and do so by spending money, then maybe... but I doubt it.

From what I see, the only true way to fix this system is to scrap it and start over, but insurance industry and the attorneys have too much political influence to allow that to happen. Personally, I like the idea of socialized medicine. I do believe it only makes sense. Health care should be a right for all rather than a privilege for those who can afford it. **BUT** I fear what that would look like here in the USA. I don't trust the lobbyists, I don't trust our government. I won't claim to have the answer, other than to know that it depends on addressing ALL of the issues I've raised here. Until that happens and someone is willing to take on ALL of those issues, things are only going to get worse.

@oakie:

A couple of critical problems with virtually every critique of the Canadian healthcare system:

1.) Canada has some particularly nativist laws on the books making it virtually impossible for foreign doctors to practice in Canada, which is what usually leads to the "shortages" in Canada. It has nothing to do with the healthcare or health insurance system.

2.) Canada spends half as much per capita on healthcare as we do, and has generally similar (if not better) results. Do you think we'd hear a single complaint in terms of care received if we poured our extravagant sums of money into a single-payer system?

@Tux the Penguin: well universal health care delivers better results at a lower cost in the UK, France, Germany (put in by Bismark that liberal), Sweden, Norway, Japan, Switzerland, Italy, Greece, Isreal, need I go on? I want to know what system you propose that will lower our health care costs in half (what France is at compared to us and they are the next highest in the world) and provide better results like these countries (live longer, lower infant mortality). Let us know your plan or let us know where a system anywhere in the universe does this that is not universal health coverage.

a government official would be making the call in a state-managed system, one significant difference would be that the government should be looking to maximize public health,

You mean like the shining success at Walter Reed? And the fine care we give our vets with head trauma? I can't wait for that. Gives me a warm feeling.

Seriously, name one thing that the government does well. Taxes DMV? Infrastructure upkeep? Drug War? Foreign policy? IRS? Simplicity in our tax code?

You want these people telling you what they're going to cover.

@poodlepoodle: Well why do these other countries have cheaper coverage with better results then? Not efficient? Are you saying you can be less efficient but somehow deliver better results at a cheaper price?

@renilyn: correct

@hegemonyhog: actually Canada spends less than half of what we do per capita. And their results are superior. We do get the privilege of funding their cheap prices on prescription medications though.

@poodlepoodle:

The funny part is almost all of those programs are either naturally botched or botched through the actions of the same people who oppose universal health care.

I also find it hilarious that anyone who's a regular reader of this site is holding up private industry as the paragon of efficiency and responsiveness.