By Dr. Jason Brown
Given my recent experience as a husband of a patient in the medical system, I found an article that appeared in the Wall Street Journal particularly interesting. I happened across it as I was seeking a diversion from the stack of cryptic EOBs (explanation of benefits), bills and letters from our insurance carrier relating to the recent birth of our son.
It was the story of James Mannett. James is a 41-year-old health conscious retired General Electric executive. Upon retiring from GE, he started a small business and realized he needed to find health insurance. He researched various plans, finally deciding on a policy guaranteeing it would cover all expenses above a yearly $5,000 deductible. Keep in mind that Mr. Mannett was a well educated former executive for a multinational corporation, and I would guess he had reviewed plenty of business documents and contracts in his previous life.
Unexpectedly, Mr. Mannett developed severe abdominal pain shortly thereafter and a visit to the emergency room revealed a tangerine-size mass in his small intestine and multiple areas in his liver where the tumor had spread. A biopsy suggested the tumor to be a relatively rare cancer called a neuroendocrine tumor, sometimes called a carcinoid. Aside from pain, carcinoids can be associated with fatigue, weight loss, flushing, watery diarrhea and a variety of other symptoms. Mr. Mannett likely did not feel well.
James sought consultations from many physicians. He unsuccessfully underwent surgery at Cedars-Sinai in Los Angeles to remove the tumors, developing a complication necessitating re-operation and a longer stay in the hospital. After recovering, he pursued another treatment involving placement of a pump in the abdomen which injects chemotherapy directly into the liver tumors. According to the article, the tumors are still present, but have decreased in size. James has to periodically undergo repeat treatments, which can flair his symptoms, and it is likely these treatments will buy some time but will not cure the disease.
The point of the Journal article was that James discovered during his ordeal that his insurance coverage was not as straightforward when the fine print was examined closely. James received enormous bills because he sought care “out-of-network” (keep in mind many of the therapies he was researching were likely not available “in-network”) and his insurance required not only the $5,000 deductible, but would only pay 80 percent of what James’ insurance thought was a reasonable charge for the “out-of-network” care. James was responsible for the remaining hundreds of thousands of dollars.
Anecdotally, I will tell you that when our staff at the office tries to get pre-approval for some therapies from insurers, they are sometimes told that the patient will have to get treated and only then can a determination about coverage be made. This can leave patients caught between accepting treatment, potentially facing huge bills, or refusing beneficial therapies because of financial uncertainty. The insurance company’s stance is akin to my going to the grocery store and only paying 80 percent (or maybe not paying at all) of what I thought the groceries were worth AFTER I ate them. And actually getting away with it.
The WSJ praised James because through constant scrutiny of his insurance documentation and calls to his insurance carriers, physicians and hospitals he was able to negotiate down his bills. Unfortunately, I took away that James had been robbed, not only of his money, but of his precious time which will likely be spent arguing with insurers and combing through paperwork as he continues to deal with the worsening symptoms of his cancer and ongoing treatments.
I am hopeful that any new health care system this country sees would allow people like James to spend his days with his family pursuing his interests, not fighting insurers and bureaucrats. Unfortunately, the new system will likely be designed by those same insurers and/or bureaucrats with little input from people like James Mannett.
Dr. Brown is a member of the Meadville Medical Center medical staff. Appointments can be made by calling the Yolanda G. Barco Oncology Institute at 373-2335.
