My first “career” out of college was in the health insurance industry. I worked for two prominent HMOs in California over a span of eight years. I came to dislike it intensely for a variety of reasons, and so despite the many skills and lessons I learned, I was glad to leave the HMO world behind when my son was born.
However, occasionally that world fills my thoughts once again. A recent news story brought it all back: the odd, dysfunctional relationship between money and medicine, public perception and corporate processes.
A young woman died recently while waiting for a liver transplant. What makes this case unusual is that her family is pursuing manslaughter or murder charges against their health insurance company.
The insurer initially determined that there was not enough evidence to suggest that the transplant would be successful given the girl’s situation. Just hours before she was taken off life support and passed away, the insurer decided to grant an exception and cover the surgery. The family feels that the company waited until it was too late in order to save themselves from paying for the procedure.
I’ve read several quotes from the family and their attorney that use words like “bean counter,” meaning that they believe the only consideration the insurer made was a monetary one.
I can shed some light on what might have happened, because back when I was in the industry, I worked with the physicians and nurses who make these decisions. Essentially the process is that a team of physicians and nurses review the appeal, considering the patient’s medical history and insurance coverage, supporting documentation in medical publications and references, and the insurer’s internal policies (there are timeframes to be adhered to, information that must be submitted, etc.). The decision is made based on whether the consensus of medical opinion is that the procedure or medication would be effective and is within the bounds of the coverage the person has.
If the requested treatment is considered experimental, or the potential outcomes are so low that the treatment is not considered effective, then the appeal will normally be denied. In the case of this young woman, given the overall poor state of her health (she had multiple organ failure as a result of a complication from a bone marrow transplant given to treat leukemia, and was being kept in a coma), and the fact that the immunosuppressant drugs given after a transplant may hasten the development of tumors, the insurer evidently felt that a transplant was not a reasonable or effective treatment.
One wrinkle is that the physicians at the hospital stated that “patients in situations similar to [the young woman’s] who undergo transplants have a six-month survival rate of about 65 percent,” which they felt was sufficient to warrant her undergoing the transplant.
The thing to remember here is that the insurance company cannot tell the hospital what to do. The hospital could have gone ahead and done the transplant without the insurer’s approval. The insurer wouldn’t have paid for it, but hospitals quite often do complicated surgical procedures out of charity. Funny how no one thinks it’s immoral for the hospital to have kept the girl waiting for a transplant until they were assured of payment!
There are two separate things going on here. One is the medical situation, where at least one group of physicians (those at the hospital) felt the transplant was warranted, and another (at the insurer) did not.
The other is the financial situation. Now, I’m not saying that insurance companies don’t think about money. Of course they do–they’re businesses, often corporations with shareholders. But the intersection between the medical and the financial realms does not come into play at this point in the process. When someone requests an exception to the insurer’s rules like this, the only consideration is what is called “medical necessity.” I never once heard any talk of financial considerations during the appeal process while I was working in the field. And insurance companies pay astronomical amounts of money for transplants and other care every day. (Sometimes we call my son “our million-dollar baby,” because the total bills for his hospital stay at birth were somewhere near $1 million. The hospital alone billed our insurance for over $600,000. That doesn’t include the charges from the surgeons themselves, or the ambulance, or any of the myriad other providers. We paid $250 total out of pocket.)
The medical and financial realms come together long before, when the patient’s employer buys the insurance coverage in the first place. The employer, when not otherwise bound by law (as in the memorable case of Catholic employers in California being required to include coverage for birth control if they wanted to offer any pharmaceutical coverage at all), can pick and choose to some degree what kinds of things are covered, based on what things the insurer offers.
So depending on the financial clout of the employer, some people have incredible insurance coverage–everything under the sun, including acupuncture, chiropractic, and expensive fertility treatments, for very low cost– while other people only have basic coverage at a higher cost.
I don’t know why in this case the insurer decided at the last moment to relent. It may have at that point been a public relations consideration, given that there were protests outside the insurer’s headquarters. But I can say that no one I encountered in that industry took anyone’s death lightly. They’re not “bean counters” or insurance weasels, or any other epithet so easily thrown–they’re human beings.
And people seem to easily forget that the insurance company can never tell you what medical care you can have…they just don’t have to pay for it. If we don’t like the fact that financial considerations affect our medical care, then we need to figure out a different relationship between the two realms.
HMOs originally came into being to help reduce spiraling medical costs in the US. That worked for a while, and HMOs also revolutionized the area of preventive care, making routine testing and simple health screenings common and thus saving many lives. However it seems like we are now dissatisfied with the taint of corporate finances on our medical system.
That’s fine with me. Go ahead and change it. But don’t be so hypocritical as to criticize a business for trying to work both ends of the stick they’re given, the medical and the financial. (And don’t criticize me for the oddness of that metaphor–it’s late, and I’m tired!)