Heroines of Bone Marrow Transplant for Metastatic (Stage IV) Breast Cancer versus Health Maintenance Organization (HMO)
Stem cells from cord blood is used to treat cancer
Three heroines fought for the best treatment against health care providers that opted for the cheapest of doubtful quality
In the past, insurance companies dodged coverage of bone marrow transplants (BMT) as part of treatment of Stage IV breast cancer. At this stage, cancer has spread to distant organs. Recommended treatments are surgery and chemotherapy.
The administration of chemotherapy drug at high dose for metastatic breast cancer has a side effect of disabling the bone marrow to produce new blood. The practice is, before chemotherapy, to harvest part of the bone marrow, preserve it, then transplant it back to the patient once the chemotherapy treatment is over.
One way insurance and health care dodge coverage is to make the terms ambiguous. Another way is to say that the insurance does not cover “experimental,” or “investigative,” or “unproven modes of treatment.”
Managed health care in the United States always opts for the cheapest means of treatment. Bone marrow transplant is expensive.
Cases of three women paved the way for the explicit insurance and health care coverage of BMT as part of treatment of Stage IV breast cancer. Here are brief accounts of two of the three women.
In September 8, when I posted this Hub I was depressed by the fate of these heroines that I settled to write the account of only two. Five hours later, I found a comment by J Burgraff, a Hubber and Commenter III. I have replied to her query and conveyed to her my congratulations for being in the bone marrow donor registry. Subsequently, I have been encouraged to give an account of the third heroine, Janice Bosworth, in fairness to her, and to give an example of one who had a bone marrow transplant and got well. Her recovery has enlivened me.
In 1993, she was diagnosed as suffering from Stage IV breast cancer. Her oncologist recommended BMT as an option. She went for an evaluation at the University of Colorado. However, her insurer said it will not pay for BMT because “it is not uniformly accepted as proven and effective for the treatment of metastatic breast cancer.”
She went for another consultation at the University of California Los Angeles (UCLA) but said she was not sure about insurance coverage and might try to raise money for the transplant.
The doctor at UCLA explained the risks of BMT like 5 percent mortality rate and long recovery from the high dose of chemotherapy. But the fact that the option of BMT was open was satisfactory enough for Christine and husband, Allan.
It turned out the couple could not raise the money fast enough, forcing Christine to mention about her insurance coverage. Her doctor said he was willing to get BMT for her if that was what she wanted. However, he was constrained being in the insurance panel of transplant and has obligations to the health care standards.
Her doctor at UCLA wrote the insurance firm to say that as a physician he had the responsibility to represent the interest of Christine and “to help her achieve her goals of her health care.”
In the next conversation with Christine this doctor said: “This procedure is of unproven efficacy in the treatment of metastatic breast cancer, and the results of clinical trials to date are not sufficient to establish beyond doubt that it is superior to standard dose chemotherapy” (Anders, G. Health Against Wealth. 1996:126).
The boss of Christine’s doctor at UCLA came up with a solution. Christine would be administered BMT at UCLA and not pay for it. The insurance firm would not pay for it either. UCLA absorbed the cost of more than $100,000 charged to reserve funds of one department of UCLA.
UCLA took this option to avoid a controversy and a costly litigation procedure that occurred over the Nelene Fox case that set a precedent on BMT and insurance companies. Christine and her husband "didn't feel that UCLA's generosity made everything right."
In the middle of 1995 a California arbitration panel “ruled in favor of the deMeurers’s claims awarding $ 1 million and legal cost to Alan deMeurers and his wife’s state.” It found fault in the insurance firm’s “’ambiguous’ definition of investigative procedures….” (Anders:130-131).
Her chemotherapy and bone marrow transplant enabled Christine to live 18 months longer.
In 1992, her case reached the doctor executive of the insurance firm. She was the mother of three children, made a beneficiary of her husband. In 1991 her cancer had metastasized reaching her bone marrow. Her oncologist urged her and her husband to consider BMT. A doctor at Southern California Norris Cancer Institute evaluated her as a “good candidate.”
Her primary-care gatekeeper believed her husband’s insurance firm would not pay for her BMT because it is unproven and experimental.
Nelene tried to "raise more than $200,000 from acquaintances while battling a terminal disease." After her BMT, she lived eight months more.
Nelene was already dead of cancer when her case was tried in court, filed by her brother, and surviving husband.
The jury “awarded Jim Fox and his wife’s estate $12 million in actual damages and another $77 million as punitive damages” (Anders, G. Health Against Wealth. 1996:128).
One juror said: “You cannot substitute profits for good-quality health care.”
The insurance firm negotiated for a reduction, down to “$ 5 million to settle the case….”
Janice, 31 years old, was a successful sales manager of a health provider. In August 1991, she made a surprise visit to one of the administrators of her employer and insurer about her own breast cancer. It had spread to her liver. Her oncologist, Dr. Gary Davidson, told her her best chance of survival was to go through a high-dose chemotherapy to be followed by a bone marrow transplant (BMT). She did not know the cost of BMT. She had arranged for a consultation with the Duke University. The medical director of her company had the cost estimate so she went to his office. When she arrived the medical director was talking with someone on the phone with his back to the door; he was not aware that Janice could hear the conversation.
She heard the medical director say: "How did she find out about Duke?"
It was clear that the subject of conversation was Janice's case. The doctor of the insurance company should not have allowed Janice to have another consultation; she should have been discouraged about BMT.
"The fact that her own doctor had told her about a potentially lifesaving therapy wasn't seen as good news; it was being viewed with disapproval" (Anders, G. Health Against Wealth. 1996:113).
When the conversation was over, the medical director turned around to find Janice in front across his table.
He told her: "I"m sorry you had to hear that...It's hard with these open cubicles. No doors" (same source as above).
Her insurance company paid for Janice's therapy, including BMT, in her chosen hospital, City of Hope National Medical Center. Two years later, she was disease-free.
What made her employer and insurer foot the bill for Janice? Rita Duarte, her long-time boss and one of the top five executives, reminded the medical director that Janice was a valued employee who had brought in a lot of profits for the company.
Janice Bosworth testified in favor of Nelene Fox in the court trial of a case filed by Nelene's husband and brother against the insurer of Fox which was also Janice's employer and insurer. When asked why she testified she said that her insurer had not learned a lesson from what it had gone through with her case.
Christine deMeurers and Nelene Fox shared the fate of some heroes and heroines: they both died of cancer. Janice Bosworth had a new lease on life. The battles they fought and won are bound to benefit future and insured victims of metastatic breast cancer.
New entries as of February 23,2013
New methods of treating cancer have been developed like stem cell therapy. The cord blood can be used. It is collected from the placenta and preserved in a blood bank. When the person born with it becomes afflicted with cancer like leukemia later on, cord blood can be thawed; stem cells are extract and grown then transplanted to him/her. There will be no rejection. When used on a relative, rejection will be very unlikely. Stem cell therapy eschews the need for bone marrow donor.
Still in the development stage is gene therapy. I have elaborated this cure in my two Hubs, "Better than chemotherapy, the new method to cure cancer," and "Patient-friendly and safe is the new cancer cure." Nitric oxide, a free radical, is used to kill cancer cells. The gene of the enzyme that produces nitric oxide is delivered in a precise manner to cancer cells. Once in cancer cells this gene induces the production of enzyme produces nitric oxide. This cure has no side effect. It is safe.