7 ms·

Big Insurance Met Match When Turned Down a Lawyer's Request for Cancer Treatment

95 points by thehoff 3y ago

rurban 3y ago
US nonsense only. In democratic countries I never heard of such shenanigans. Some costly treatments are denied, yes, but not in such clear cases.
Something1234 3y ago
Honestly, a really good story well written. Should be read by more people. It's really quite strange how opaque most of these processes are. How they are handled and documented is also quite nuts.
- lozenge 3y ago
  Strange? More like inevitable given the incentives involved.
kylecazar 3y ago
Kind of demoralizing story (but a good read). Even a renowned litigator with the right friends and plenty of money was only able to secure (potentially partial) payment for the treatment? The system doesn't even allow for damages? Almost made me even more frustrated. I was hoping they'd have to pay up big time, or that some legal precedent would be set in his victory that would help millions in the future avoid this mess. Also title could use a 'treatment' added to it.
- lotsofpulp 3y ago
  >and plenty of money was only able to secure (potentially partial) payment for the treatment? They did not even receive a partial payment yet, though, 5 years after the event. >The case itself remains open. The judges ruled that Blue Cross must pay for Salim’s treatment. But they did not say how much. >Salim is expecting the full $95,862.95 he paid. However, court records show that Blue Cross has said it only needs to pay Salim the discounted rate it had negotiated with MD Anderson at the time of his radiation treatment: $35,170.47. That’s what Blue Cross would have paid if its doctors had said yes in the first place. >A decision is expected later this year. Shows you how much you should depend on the courts if you are not already rich.
lukev 3y ago
Pretty much the same thing happened to my dad. He was diagnosed with a rare type of blood cancer. The insurance company denied monoclonal antibodies (as recommended by his oncologist) and would only pay for a complete bone marrow transplant, which would have been highly traumatic at his age. All based on a "standard of care" that at that point was 15 years old... and which was originally written by a committee chaired by my dad's oncologist (who presumably knows something about the best way to treat this condition in 2022.) They didn't reverse the decision until we got a lawyer who knew the ins and outs of the appeals process. Thankfully, we were able to work through that fast enough for treatment to be effective... there's no way we could have paid out of pocket. The ability of an insurance company to unilaterally deny treatment, or determine what type of treatment a patient receives, is obscene and should be categorically illegal. There is no instance in which a medical bureaucrat should should be able to, sight-unseen, overrule a patient's own doctor. It's so frustrating.
- MichaelZuo 3y ago
  Why shouldn't insurance companies offer cheaper plans that don't include state of the art treatments? Not everyone wants to pay top dollar for the most comprehensive gold-plated plans.
  - resoluteteeth 3y ago
    So you want to pay $450 rather than $500 a month and in exchange when you get cancer they tell you to just go die rather than getting the treatment your doctor prescribes that could save you? Isn't the whole point of insurance covering that type of situation?
    - MichaelZuo 3y ago
      Huh? I'm not currently planning to purchase health insurance in the US. Are you confused about my comment?
    - chii 3y ago
      > Isn't the whole point of insurance covering that type of situation? it is, but i imagine the insurance company is expecting a certain cost for some expected treatments, and use that to calculate your life-time value as a customer. If a new treatment that has better outcomes, but is more expensive comes along, the insurance company may stand to lose money, and thus, they prefer denying such a treatment and only offer the "old" one. At least, that is how i would rationalize the behaviour. Whether this is actually the reason or not, remains to be seen.
Kim_Bruning 3y ago
I remember the mention of "Death Panels" that were claimed would appear if there was federal insurance. I'm not sure, but isn't that what's happening today as is? * https://en.wikipedia.org/wiki/Death_panel https://en.wikipedia.org/wiki/Death_panel
- paulddraper 3y ago
  > but isn't that what's happening today as is? Yes. The difference is how much choice you have for your death panel.
  - deleted 3y ago
    [deleted]
  - Kim_Bruning 3y ago
    I think "death panels" were a propaganda thing unique to the USA. They don't actually exist anywhere (else) afaik.
    - theGnuMe 3y ago
      They exist in the UK and Canada where they will deny treatments for similar reasons or if deemed too expensive.
      - Kim_Bruning 3y ago
        Do you have a reliable source? (edit: I found a speech by Stephen Hawking on the matter: https://www.hawking.org.uk/in-words/speeches/speech-1 https://www.hawking.org.uk/in-words/speeches/speech-1 Quick summary: At the start of the speech he refutes a claim that death panels exist in the UK NHS and that they would have let him die. Of course the strongest refutation is the fact that he was at the time -in fact- quite alive; thanks to the NHS. )
        wpasc 3y ago
        https://amp.theguardian.com/society/2016/dec/29/breast-cancer-drug-kadcyla-rejected-for-nhs-use-on-cost-benefit-grounds https://amp.theguardian.com/society/2016/dec/29/breast-cance... It’s not disputed nor unknown that a variety of expensive/newer cancer treatments are not payed for by the NHS. I posted one example but there are many
starkparker 3y ago
Didn't expect to see Skeeter Salim on Hacker News. Like, ever, much less in this context. Trial attorneys have a very peculiar reputation in Louisiana. They get incredibly wealthy on the backs of lawsuits against the state's oil and gas businesses and their insurers, then turn that money into political lobbying power. This creates a populist dynamic where trial attorneys try to rally voters to oppose tort reform laws in the legislature that are often backed by insurance companies. For instance, in the Louisiana gubernatorial election, where Salim shows up in this article: https://www.nola.com/news/politics/jeff-landry-is-collecting-big-donations-from-trial-lawyers/article_ae9755b0-4394-11ee-b5b5-0b41f4b6fc3f.html https://www.nola.com/news/politics/jeff-landry-is-collecting...
- theGnuMe 3y ago
  Good. We don’t need tort reform we need more lawsuits against bad companies.
  - TheCoelacanth 3y ago
    "Tort reform" is a euphemism for "everything must be secondary to shareholder value, even to the extent of making it impossible to punish egregious violations of the law".
refurb 3y ago
Here is the fun part that most people don't know...universal healthcare systems wouldn't have paid for this either. However, the patient never would known about it because it wouldn't have been on the list of "approved therapies", so the doctor never would have suggested it. The article dances around it, but for this particular cancer, proton beam therapy has little evidence supporting it. The current treatment guidelines like NCCN list a number of evidence-based therapies for first line, second line and subsequent line treatments. Proton beam thereapy is a "hail mary" and universal healthcare systems are less expensive than the US because they don't pay for "hail marys". So in places like Canada (whose patients, it's important to note, need to travel to the US because there are no proton beam centers) the doctor wouldn't have even considered it as a treatment option in this case.
- toomuchtodo 3y ago
  This is a valid point about gating of medical procedure access, but more an argument for exception processes and cost reductions to allow off label attempts at treatment. I see the price of proton therapy varies wildly between thousand and tens of thousands of dollars per treatment. Still too high. Perhaps if the cost were lower and some streamlined review process existed, it would be less of a lift to say “hop on the table while the accelerator spins up, won’t be expensive if this doesn’t work.” (in this example) Rationing human supply (labor) makes sense, making humans takes time and supply is constrained. Other costs can be ruthlessly driven down (with some combination of manufacturing learning, research, etc). Consider the costs of Western disease (obesity) and bariatric surgery with recent developments in semaglutide, for example.
  - nradov 3y ago
    On what basis are you claiming that the cost of proton beam therapy is too high? How do we calculate the correct price? Newer medical devices will always be expensive due to the high costs of R&D plus obtaining FDA approval.
    - toomuchtodo 3y ago
      Proton therapy has existed for decades. I’m claiming the costs are too high based on today’s dollars, and is an opinion. Cyclotrons can cost anywhere from low 7 to mid 8 figures, but cyclotron time can be had as cheap as $1100/hr at certain labs. Offering someone experimental or unproven protocols is more palatable if treatment costs closer to $10k vs $100k. On what basis are you claiming that the cost of proton beam therapy is not too high? https://en.wikipedia.org/wiki/Proton_therapy https://en.wikipedia.org/wiki/Proton_therapy
hooverd 3y ago
Inspiring! Orphan's knowledge of legal system saves them from orphan crushing machine.
mnky9800n 3y ago
I like the part where everyone forgot that humans are more important than money.
cyanydeez 3y ago
"don't get cancer unless you're a lawyer"

95 points by thehoff 3y ago

US nonsense only. In democratic countries I never heard of such shenanigans. Some costly treatments are denied, yes, but not in such clear cases.

Something1234 3y ago

Honestly, a really good story well written. Should be read by more people. It's really quite strange how opaque most of these processes are. How they are handled and documented is also quite nuts.

lozenge 3y ago
Strange? More like inevitable given the incentives involved.

kylecazar 3y ago

Kind of demoralizing story (but a good read). Even a renowned litigator with the right friends and plenty of money was only able to secure (potentially partial) payment for the treatment? The system doesn't even allow for damages? Almost made me even more frustrated. I was hoping they'd have to pay up big time, or that some legal precedent would be set in his victory that would help millions in the future avoid this mess. Also title could use a 'treatment' added to it.

lotsofpulp 3y ago
>and plenty of money was only able to secure (potentially partial) payment for the treatment? They did not even receive a partial payment yet, though, 5 years after the event. >The case itself remains open. The judges ruled that Blue Cross must pay for Salim’s treatment. But they did not say how much. >Salim is expecting the full $95,862.95 he paid. However, court records show that Blue Cross has said it only needs to pay Salim the discounted rate it had negotiated with MD Anderson at the time of his radiation treatment: $35,170.47. That’s what Blue Cross would have paid if its doctors had said yes in the first place. >A decision is expected later this year. Shows you how much you should depend on the courts if you are not already rich.

lukev 3y ago

Pretty much the same thing happened to my dad. He was diagnosed with a rare type of blood cancer. The insurance company denied monoclonal antibodies (as recommended by his oncologist) and would only pay for a complete bone marrow transplant, which would have been highly traumatic at his age. All based on a "standard of care" that at that point was 15 years old... and which was originally written by a committee chaired by my dad's oncologist (who presumably knows something about the best way to treat this condition in 2022.) They didn't reverse the decision until we got a lawyer who knew the ins and outs of the appeals process. Thankfully, we were able to work through that fast enough for treatment to be effective... there's no way we could have paid out of pocket. The ability of an insurance company to unilaterally deny treatment, or determine what type of treatment a patient receives, is obscene and should be categorically illegal. There is no instance in which a medical bureaucrat should should be able to, sight-unseen, overrule a patient's own doctor. It's so frustrating.

MichaelZuo 3y ago
Why shouldn't insurance companies offer cheaper plans that don't include state of the art treatments? Not everyone wants to pay top dollar for the most comprehensive gold-plated plans.
- resoluteteeth 3y ago
  So you want to pay $450 rather than $500 a month and in exchange when you get cancer they tell you to just go die rather than getting the treatment your doctor prescribes that could save you? Isn't the whole point of insurance covering that type of situation?
  - MichaelZuo 3y ago
    Huh? I'm not currently planning to purchase health insurance in the US. Are you confused about my comment?
  - chii 3y ago
    > Isn't the whole point of insurance covering that type of situation? it is, but i imagine the insurance company is expecting a certain cost for some expected treatments, and use that to calculate your life-time value as a customer. If a new treatment that has better outcomes, but is more expensive comes along, the insurance company may stand to lose money, and thus, they prefer denying such a treatment and only offer the "old" one. At least, that is how i would rationalize the behaviour. Whether this is actually the reason or not, remains to be seen.

Kim_Bruning 3y ago

I remember the mention of "Death Panels" that were claimed would appear if there was federal insurance. I'm not sure, but isn't that what's happening today as is? * https://en.wikipedia.org/wiki/Death_panel https://en.wikipedia.org/wiki/Death_panel

paulddraper 3y ago
> but isn't that what's happening today as is? Yes. The difference is how much choice you have for your death panel.
- deleted 3y ago
  [deleted]
- Kim_Bruning 3y ago
  I think "death panels" were a propaganda thing unique to the USA. They don't actually exist anywhere (else) afaik.
  - theGnuMe 3y ago
    They exist in the UK and Canada where they will deny treatments for similar reasons or if deemed too expensive.
    - Kim_Bruning 3y ago
      Do you have a reliable source? (edit: I found a speech by Stephen Hawking on the matter: https://www.hawking.org.uk/in-words/speeches/speech-1 https://www.hawking.org.uk/in-words/speeches/speech-1 Quick summary: At the start of the speech he refutes a claim that death panels exist in the UK NHS and that they would have let him die. Of course the strongest refutation is the fact that he was at the time -in fact- quite alive; thanks to the NHS. )
      - wpasc 3y ago
        https://amp.theguardian.com/society/2016/dec/29/breast-cancer-drug-kadcyla-rejected-for-nhs-use-on-cost-benefit-grounds https://amp.theguardian.com/society/2016/dec/29/breast-cance... It’s not disputed nor unknown that a variety of expensive/newer cancer treatments are not payed for by the NHS. I posted one example but there are many

starkparker 3y ago

Didn't expect to see Skeeter Salim on Hacker News. Like, ever, much less in this context. Trial attorneys have a very peculiar reputation in Louisiana. They get incredibly wealthy on the backs of lawsuits against the state's oil and gas businesses and their insurers, then turn that money into political lobbying power. This creates a populist dynamic where trial attorneys try to rally voters to oppose tort reform laws in the legislature that are often backed by insurance companies. For instance, in the Louisiana gubernatorial election, where Salim shows up in this article: https://www.nola.com/news/politics/jeff-landry-is-collecting-big-donations-from-trial-lawyers/article_ae9755b0-4394-11ee-b5b5-0b41f4b6fc3f.html https://www.nola.com/news/politics/jeff-landry-is-collecting...

theGnuMe 3y ago
Good. We don’t need tort reform we need more lawsuits against bad companies.
- TheCoelacanth 3y ago
  "Tort reform" is a euphemism for "everything must be secondary to shareholder value, even to the extent of making it impossible to punish egregious violations of the law".

refurb 3y ago

Here is the fun part that most people don't know...universal healthcare systems wouldn't have paid for this either. However, the patient never would known about it because it wouldn't have been on the list of "approved therapies", so the doctor never would have suggested it. The article dances around it, but for this particular cancer, proton beam therapy has little evidence supporting it. The current treatment guidelines like NCCN list a number of evidence-based therapies for first line, second line and subsequent line treatments. Proton beam thereapy is a "hail mary" and universal healthcare systems are less expensive than the US because they don't pay for "hail marys". So in places like Canada (whose patients, it's important to note, need to travel to the US because there are no proton beam centers) the doctor wouldn't have even considered it as a treatment option in this case.

toomuchtodo 3y ago
This is a valid point about gating of medical procedure access, but more an argument for exception processes and cost reductions to allow off label attempts at treatment. I see the price of proton therapy varies wildly between thousand and tens of thousands of dollars per treatment. Still too high. Perhaps if the cost were lower and some streamlined review process existed, it would be less of a lift to say “hop on the table while the accelerator spins up, won’t be expensive if this doesn’t work.” (in this example) Rationing human supply (labor) makes sense, making humans takes time and supply is constrained. Other costs can be ruthlessly driven down (with some combination of manufacturing learning, research, etc). Consider the costs of Western disease (obesity) and bariatric surgery with recent developments in semaglutide, for example.
- nradov 3y ago
  On what basis are you claiming that the cost of proton beam therapy is too high? How do we calculate the correct price? Newer medical devices will always be expensive due to the high costs of R&D plus obtaining FDA approval.
  - toomuchtodo 3y ago
    Proton therapy has existed for decades. I’m claiming the costs are too high based on today’s dollars, and is an opinion. Cyclotrons can cost anywhere from low 7 to mid 8 figures, but cyclotron time can be had as cheap as $1100/hr at certain labs. Offering someone experimental or unproven protocols is more palatable if treatment costs closer to $10k vs $100k. On what basis are you claiming that the cost of proton beam therapy is not too high? https://en.wikipedia.org/wiki/Proton_therapy https://en.wikipedia.org/wiki/Proton_therapy

hooverd 3y ago

Inspiring! Orphan's knowledge of legal system saves them from orphan crushing machine.

mnky9800n 3y ago

I like the part where everyone forgot that humans are more important than money.

cyanydeez 3y ago

"don't get cancer unless you're a lawyer"