( - promoted by David)
"A lot of this is UniCare basically administering the rules based on our customer, in this case the Group Insurance Commission." --Tony Felts, spokesman for Unicare Hannah Coler is an Amherst native and UMass student. She was diagnosed with diffuse sclerodoma. Because the disease, which hardens the skin, and eventually the internal organs, is progressing rapidly in her case, Coler's doctors think she should "participate in the Scleroderma: Cyclophosphamide or Transplantation, or SCOT, trial." Unicare, Coler's father's insurer, however, and Group Insurance Commission (GIC) to which it belongs, say NO. The Daily Hampshire Gazette reports: The SCOT trial patients take one of two treatment routes: either high doses of the chemotherapy drug Cytoxan or a stem cell transplant. The trial compares the results of the two for mortality and organ damage. |
UniCare officials, in three separate letters, wrote that the SCOT trial is not a covered benefit.... The insurance company considers the SCOT trial experimental, says it's not medically necessary, and maintains that it lacks evidence of effectiveness. The Colers received a denial letter from UniCare stating, in part, "The fact that a physician ordered it or that this treatment has been tried after others have failed does not make it medically necessary." Tony Felts, a spokesman for UniCare, said health plans often contain exclusions for coverage pertaining to medical trials. "A lot of this is UniCare basically administering the rules based on our customer, in this case the Group Insurance Commission," Felts said. In a sad twist of fate, Coler's father had switched from Blue Cross Blue Shield to UniCare so the family could see doctors outside of network. He could have chosen from other providers, including Blue Cross Blue Shield, Cignet and Uniform Medical, which have provided coverage for the SCOT trial. When the Colers appealed Unicare's decision, the GIC sided with the insurer. GIC Executive Director Dolores Mitchell wrote, in a Nov. 12 letter, "I regret that the appeals committee decision could not be more favorable to you and Ms. Coler, but the language provided on the SCOT trials Web site establishes that this trial is investigational and that the treatments provided are not standard medical treatment for systemic scleroderma." Andrew Coler disagrees. "The SCOT study is the only proven, and most effective, treatment," Coler said. "It's got a very good track record, and it's documented that people have made a full recovery."
From a soulless, cost-benefit point of view, I don't know if the experimental treatment requested by 21 year-old Hannah Coler and her doctor is worth it. I'm not an ethicist or an insurance company. I am a parent, however, and if there were a $300,000 treatment that gave my daughter a chance at life, I'd want it. Cost-benefit analysis be damned. As case of Hannah Coler demonstrates, rationing is alive and well and living in the private sector. It's even endorsed by our quasi-independent representatives at the GIC. Rationing health care is already part of the insurance game and the stakes are life and death. You can donate to the Help Hannah Coler Medical Fund here. Mark NOTE: I mistakenly said the GIC offered insurance plans that would have covered Coler's condition. Others GIC plans may indeed cover her condition, but those I mentioned were evidently available to her father through UMass, but not as part of the GIC. |
