Presbyterian Health fought Whipple at M. D. Anderson
Doing Battle With the Insurance Company in a Fight to Stay Alive
By Denise Grady
The New York Times
July 29, 2007
A glorious blend of forces came together to save Gordon Hendrickson’s life: smart doctoring, luck, kindness, and his own wisdom and abundant grit.
Only his insurance company tried to stand in the way.
His doctors thought he was among the lucky few with pancreatic cancer found early enough to be cured by surgery. But they warned him not to have the surgery in his home city, Albuquerque. They said the operation he needed, a Whipple procedure, was so risky and complicated that it should be done only by a surgeon who performed it often and at a hospital with many similar cases. But neither was available locally.
…his internist, Dr. Kristine Bordenave… canceled her other appointments to spend hours on the phone finding a major cancer center that would quickly admit him. It turned out to be the M. D. Anderson Cancer Center in Houston.
But his insurer, the Presbyterian Health Plan, refused to pay for treatment in Houston. The company insisted that the operation be done in Albuquerque and sent him a list of five local surgeons.
He went to M. D. Anderson anyway.
Mr. Hendrickson had the surgery. It went well. But he was left with more than $80,000 in medical bills, which Presbyterian Health Plan refused to pay.
Mr. Hendrickson waged a long battle with Presbyterian.
After Presbyterian rejected two appeals, he took his case to a state review board, where he represented himself because he could not afford a lawyer.
Ultimately, Mr. Hendrickson won the case, and Presbyterian Health Plan paid the entire bill.
About Presbyterian Healthcare Services:
http://www.phs.org/admin/about_us.shtml
Comment:
By Don McCanne, MD
The appropriate medical decision could not be more straightforward. A Whipple procedure should always be done in a center with an experienced team. To attempt this operation at a local level with an inexperienced team is almost tantamount to a death sentence.
Had Mr. Hendrickson been covered by the traditional Medicare program, the referral would have been made promptly to M. D. Anderson Cancer Center without the need to consider any other referral options, the operation would have been completed, and Medicare would have paid the bills. End of story.
But no. His coverage was through Presbyterian Health Plan, an intrusive third party payer that held contracts with the patient on the consumer side, and with a specific list of physicians and hospitals on the provider side. The contracts allowed Presbyterian Health Plan to use a basic business decision to overrule a crucial medical decision. This clearly caused Mr. Hendrickson considerable distress, and could have cost him his life.
One irony is that Presbyterian Health Plan is part of Presbyterian Healthcare Services which is a private, nonprofit statewide healthcare system with several hospitals, plus primary and specialty care through Presbyterian Medical Group. Single payer model proposals usually include coverage for integrated healthcare delivery systems, as long as their mission is providing health care rather than providing insurance services.
Suppose we adopted a single national health insurance program covering everyone for all reasonable beneficial services. Presbyterian Health Plan would be superfluous and could be eliminated. Payment for services could be made directly by the public insurance program. The patient could be free to continue to use Presbyterian Healthcare Services, but could also be free to use any other healthcare providers such as M. D. Anderson Cancer Center. Neither the patient nor the providers necessarily would be locked in by a contract.
But what if the integrated healthcare delivery system elected to be funded through capitation, as some single payer models would permit? That returns some of the financial risk to the delivery system, and locks the patient back in (otherwise the government would be paying, for the same patient, both a capitation fee for comprehensive services and fee-for-service costs outside of the system). The single payer model does call for funding hospitals through global budgets, so the hospital component of the integrated delivery system could be funded by global budgets as well. The medical group component could then be funded either by fee-for-service, or also by a global budget negotiated to cover legitimate costs plus fair compensation. Paying physicians by salary reduces the incentives to either withhold beneficial care or provide excessive services (although it risks sloth).
At any rate, Mr. Hendrickson’s experience provides us with yet one more example of why we need to remove private insurers from our financing of health care. Health care needs to be based strictly on medical need rather than on business decisions made by private insurers.