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Friday, April 23, 2010

Insurance coverage dropped for breast cancer patients

This headline screamed at me yesterday morning over my cup of coffee: "WellPoint routinely targets breast cancer patients." It's all over the internet now and raises a few questions about the treatment of patients - specifically women.

Interestingly enough, the original version of the story I read yesterday included this one brief nugget of information: That to insurers, breast cancer patients, as well as pregnant women, were an "anathema." Even as proficient as I am with the English language, I had to look that one up. It means "a person or thing, detested or loathed."

When I went back to reread the article through Reuters, I couldn't find the word "pregnancy" anywhere. Puzzled, I read the comments on the Reuters reader forum and realized, after someone noticed it, that the article had been severely edited, including the negative comments made about pregnant patients. Someone must have said something inflammatory and made the corporate lawyers mad, which prompted further editing of the article. However brief the mention was, though, at least it got some notice. (Ironically the comment was made by the city attorney of Los Angeles, not someone from the insurance carrier itself.) And while I think he is on the right track, the threat of disability is not the real reason here.

"But there are two things that really scare them and they are breast cancer and pregnancy. Breast cancer can really be a costly thing for them. Pregnancy is right up there too. Their worst-case scenario is that a child will be born with some disability and they will have to pay for that child's treatment over the course of a lifetime."

It's not news that insurance companies have been dropping pregnant women from their care for the last few years, especially in the case of a repeat c-section or the choice of doing a VBAC. For the group who don't want to do a repeat cesarean, often insurance carriers would refuse to pay for a VBAC, undoubtedly because their "panel of doctors" deemed it too dangerous. For the group who don't want to do a VBAC, the insurance carrier refused to pay for what they considered an 'elective' cesarean when a VBAC could be cheaper.

The take-home message in this particular case is that your insurance carrier is saying, "Don't get pregnant. We'll be glad to pay for your birth control pills, though." Because that baby has to come out, either way. So what is a woman to do, when her options are limited not only by her doctor, but by her insurance carrier?

In both cases of pregnancy and breast cancer, basically WellPoint uses a computer algorithm to single out particular patients. Certain conditions, apparently, "trigger investigations" with the company, even though the computer appears to be doing all the work. Apparently WellPoint is concerned about fraud, but really, when it comes to cancers, the United States has a high rate of survival for many cancers because of their rather aggressive treatment. If they're interested in investigating fraud, especially when it comes to pregnancy, perhaps they need to look into the overuse of the expensive induction agent Pitocin, which can cost hundreds of dollars per dose. Multiply that by the number of WellPoint's patients alone who are induced, whether for medical necessity or not, and I bet the figures add up very, very quickly. Or perhaps look into the number of unncesareans that are performed on their patients daily.

The difference between these types of patients is obvious: breast cancer is an illness that needs to be treated. Pregnancy is not. But either way, women are forced into neat little boxes, absolutes that are black and white. We know that the more interventions in pregnancy and labor that are performed can sometimes put the mother and baby at elevated risk, and are often extremely costly to the insurance provider. Instead of instantly dropping both groups of patients from their care, why aren't they taking initiatives to find evidence-based ways of saving money? In the case of labor and delivery, all the information is already out there, but few doctors put it into practice on a wide scale.

One thing I'm curious about: how do their treat male patients? No word on that yet. Especially those rare men who get breast cancer, because it does happen. Are they immediately dropped from their insurance carrier? Either way, it looks like women lose out again on this one.


The Deranged Housewife said...

And here is the "explanation" from WellPoint, via Time Magazine:

So just forget what that other guy said, folks. Ummm....yeah.