Posted on 12/11/2017 12:40:06 PM PST by nickcarraway
Cara Pressman sobbed in the big red chair in her living room. The 15-year-old tried to absorb the devastating news relayed by her parents: that their insurance company, Aetna, denied her for a minimally invasive brain surgery that could end the seizures that have haunted her since she was 9 years old.
“When my parents told me, I went kind of blank and started crying,” she said. “I cried for like an hour.”
Her friends had been lined up to visit her in the hospital for the surgery three days away, on Monday, October 23. Between tears, she texted them that the whole thing was off.
(Excerpt) Read more at kfor.com ...
Define cheaper. It depends on whom will pay how much for what. I spent a good bit of today trying to get cash prices for medical procedures from a medical provider. I thought cash wouldn’t be a problem. Silly me. The provider told me that I would find out what I would be charged after an appointment with a financial counselor. I told them I didn’t need or want financial counseling, just a price. I didn’t get one. Wonder if this family raises cash for the procedure, if they’ll get taken by a medical industrial complex that apparently can and does charge different patients different sums for the same damn procedure.
See my reply #21.
Fifty years ago my brother underwent surgery that cost $50,000.00. That would be $365,968.84 in 2017 dollars.
Crap like this has been going on for 30 years. When my son was an infant, he could not tolerate any formula because he was induced at 39 weeks. His intestines weren’t mature.
The answer was a “pre-digested” formula powder that was made in England. It wasn’t available here in the US. So his pediatrician recommended we get it. It was Dr. prescribed treatment. My son was 2-3 months old at the time.
Aetna rejected paying for the formula because they said they didn’t cover “supplemental nutrition”. At the time, I think this stuff was $300 for 4 cans and each can lasted about 5 days. So roughly $500 per month. I wasn’t making much then and it would have been extremely difficult.
They make decisions in a vacuum without understanding the facts. Even after long phone calls with them and my arguing that my son’s only food couldn’t possibly be “supplemental” they wouldn’t budge.
.
Doctor #1: A simple evacuation of the epidural hematoma will relieve the pressure!
McCoy: My God man, drilling holes in his head is not the answer! The artery must be repaired! Now, put away your butcher's knives and let me save this patient before it's too late!
Which tells me this is a stupid bureaucracy issue and not a cost issue at all.
If Aetna's really concerned about the "bottom line" on this one, some bureaucrat needs to look at the two costs and make the determination that this girl can have the cheaper "experimental" procedure.
Common sense is so dead in this country, isn't it?
So, the non-Aetna medical expert they interviewed defines a 20% delta as a slightly better rate? I understand that a craniotomy is more invasive, but a 20% difference in outcome is nothing to sneeze at.
There is a reason it costs $300,000.
$10,000 for the procedure, and $290,000 for the overhead for the hospital insurance, their legal team, and nurses and standby team and equipment available for every possible contingency so they can keep out of court.
Plus that machine that goes “bing”.
Why won’t her parents pay for the minimally invasive operation? Guess the don’t love her:-(
Maybe Jimmy Kimmel will rush right out and cover the costs?
Sorry but this isn't an Obamacare thing, its typical bureaucratic BS from the insurance company.........Since they consider it "experimental", it won't be covered.
Back in the late 80's there was a manager at my plant who eventually succumbed to ALS. He suffered for several years with this debilitating disease and in his last days, one of the union reps would pick him up at home and bring him to work where he was relegated to a motorized wheelchair. He only stopped coming to work when he could no longer get out of bed.
There were all kinds of experimental drugs out there but were never approved for him by the insurance company since they were still "experimental" and he certainly couldn't afford them...........
It's a really tough call and I sympathize with the young girl and her parents. But if it were me and she were my daughter, I would pay out of pocket for the surgery then enter into a payment agreement with the hospital and hope somebody starts a "Go Fund Me" website..........
So what did you end up doing?
How is your son now?
The answer was a “pre-digested” formula powder that was made in England. It wasn’t available here in the US. So his pediatrician recommended we get it. It was Dr. prescribed treatment. My son was 2-3 months old at the time.
Aetna rejected paying for the formula because they said they didn’t cover “supplemental nutrition”. At the time, I think this stuff was $300 for 4 cans and each can lasted about 5 days. So roughly $500 per month. I wasn’t making much then and it would have been extremely difficult.
They make decisions in a vacuum without understanding the facts. Even after long phone calls with them and my arguing that my son’s only food couldn’t possibly be “supplemental” they wouldn’t budge.
Searching about a bit, it does indeed look like this treatment is more or less experimental in the sense that a bunch of centers have started doing it, but haven’t bothered to run adequate studies to show efficacy.
Claims of efficacy mostly seem to be anecdotal, and the centers that are pushing this always fail to mention that it isn’t covered by insurance. It looks like NO insurance company covers this for the above reasons, and my guess is that neither does Medicare or Medicaid for the same reason.
I think this procedure goes all the way back to 2013, and yet no one has bothered to prove it’s at least as good as the open-brain surgery.
The Epilepsy Foundation states:
“LITT has not undergone any randomized control trials. Therefore, all the current data is taken from either small prospective single institution case series or retrospective reviews
LITT appears to be a highly promising alternative. Therefore, LITT is a viable option as an alternative to open surgery for the treatment of MTLE and, with continued work and research, its efficacy and indications for use in the treatment of refractory epilepsy will expand.”
So why doesn’t the Epiplepsy Foundation (or one of the two companies that make the system used for the procedure) sponsor a multi-center comparative study amongst a study group larger than 13 people instead of everyone sitting around on their thumbs whining about insurance companies? It’s the only way that they’re gonna pay, and you can hardly blame them, since there are hundreds of unproven procedures that are experimental and not covered for that reason.
Many yeats ago, I was prescribed an experimental med for a course of treatment prior to a surgery. Insurance refused to cover the cost, so we did and took the financial hit, which was a whopper. As it turned out the med did not do what it was supposed to have done and I had complications during the surgery. After I woke and found out what happened I told my surgeon now I knew why insurance refused to cover it.
Not to make light of the young lady’s plight but what if she were a convicted male criminal and wanted a Penisecktomy. The government(Uncle Sugar) would pay.
Precedents have been set!
Or they could pay $5/mo like so many do.
Yup. Any underwriter will tell you this. “Insurance” and “experimental” don’t mix. Just try to get a life insurance plan while the newspapers are doing stories about your experimental rocket that you’re building to prove the world is flat. You might be able to get a 100,000 dollars worth of coverage, for, say, a premium of 250,000.
Wake Up. RNC:
Offer this kid $500,000 to be the poster child for anti-democrat infomercials about obamacare. Run it in every district and remind the voters that this type of situation is the sole responsibility of the democrat (NOT DEMOCRATIC) party
Big Medicine shouldn’t really be doing experiments on people and expecting Big full payment. Why even bring up the existence of unproven procedures to folks and planting false hopes?
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