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House Hearing to Focus on Insurers' Denial of Treatment

By David S. Hilzenrath
As Republicans argue that Democratic health care proposals would put government bureaucrats between doctors and patients, one of the House's most liberal members is making a counter-argument: Insurance company bureaucracies are already in the way.

Rep. Dennis Kucinich, the Ohio Democrat and erstwhile presidential candidate, plans to cast a spotlight on insurance companies in hearings scheduled for Wednesday and Thursday. Kucinich chairs the House Oversight and Government Reform Subcommittee on Domestic Policy.

First he plans to air testimony about patients whose insurers refused to pay for care; then he plans to put insurance company executives in the hot seat. The witness list for Thursday includes representatives of United Healthcare, WellPoint, Aetna, Humana, and Cigna.

The lineup for Wednesday's hearing includes a woman whose father died in 2007 at age 59 after his bone marrow transplant was delayed by a dispute with BlueCross BlueShield of Montana.
William G. Ackley, who was an elementary school principal, suffered for 20 years from a form of leukemia. In April 2006, as his condition deteriorated, the insurer sent Ackley a letter saying it would not pay for the transplant because "the proposed service does not meet your policy's definition of 'Necessary.' " A peer reviewer found that under the circumstances the treatment was "investigational" -- in other words, BCBSMT Medical Director Mary Sims wrote the following month, not proven effective for his disease.

A series of appeals and denials ensued. Ackley's family asked a state regulator to get involved. Meanwhile, the National Marrow Donor Program wrote a letter to the insurer asserting that the proposed treatment was "neither investigational nor experimental" but rather was the only treatment for Ackley's disease "known to be curative."

The case isn't necessarily as simple as critics of private health insurers might like. The state of Montana designated a private organization called the Mountain-Pacific Quality Health Foundation to conduct independent reviews in such disputes. In early May, the insurer informed Ackley that Mountain-Pacific upheld the denial. More than a month later, Mountain-Pacific wrote that a second reviewer reached a different conclusion: The proposed treatment was medically necessary. The insurer's denial of coverage was reversed.

After another preparatory regimen of chemotherapy, Ackley got his transplant in August. He died the following January.

"Would there have been a different end to my dad's story if he had been given approval of the first transplant request in April 2006?" Ackley's daughter Erinn Ackley asks in draft testimony. "We don't know. What we do know is that his chance for survival most assuredly did not increase because ... Blue Cross Blue Shield of Montana built the bureaucratic roadblocks that made my father wait four months for his potentially life-saving bone marrow transplant."

The treatment at issue was covered under federal guidelines for Medicare and Medicaid, and had Ackley been old enough to qualify for Medicare, the government insurance program for older Americans, he would not have faced the delay, Erinn Ackley says in the draft testimony.
Kucinich, who chairs a subcommittee of the House Committee on Oversight and Government Reform, advocates the ultimate government-health-care plan: Medicare for all.

A spokesman for Kucinich, Nathaniel White, said the subcommittee did not try to get the insurance company's side of the Ackley story. "The documentation speaks for itself," he said.
"They could say it wasn't entirely their fault, but it does show ... how much bureaucracy someone who was on their deathbed was facing," White said.

Asked for comment, BlueCross BlueShield of Montana spokesman Tim Warner provided a statement saying federal law prohibits the company from discussing confidential patient information without authorization.

"In determining questions of coverage, it is BCBSMT's standard procedure to obtain and rely upon the opinions of qualified medical professionals, including external medical experts," Warner said.

By David S. Hilzenrath  |  September 16, 2009; 6:00 AM ET
Categories:  Health Reform , House  
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Comments

Unfortunately, the loudmouth protesters won't be watching these proceedings or won't empathize that it could just as easily be them falling victim to these predatory practices.

Posted by: fiberartist | September 16, 2009 10:37 AM | Report abuse

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