Another PMP patient is nicknamed the "Insurance Warrior" for good cause. She has battled and won over 44 appeals for herself and other patients. I'm publishing her full newsletter with her permission. Longer than usual, but good. If you want to make copies and/or share this information, Todd has given permission to copy and share. Kat
The Insurance Intelligencer
8/31/09
The $3.7 Million Man
As I go forth to speak to general audiences, people make remarks about the state of healthcare.
I heard this one last week in the farm belt of Ohio:
"The problem with healthcare these days is greedy doctors."
Treatment denied
On August 5, I received a call from Tina in Michigan. Her husband Michael had been diagnosed with metastasized abdominal cancer. He needed the same tried, proven lifesaving surgery that I had undergone four years ago.
The facts of the case:
The surgery was denied because it was "out of network."
Tina has a self-funded plan. This means that her employer gets to approve or deny Michael's treatment.
The employer is St. John Health. which is a non-profit Catholic hospital.
The insurer is Blue Cross Blue Shield of Michigan, which is also a non-profit.
After the treatment was denied in June, Tina and Michael left the appeal to their doctor. He wrote a one-page letter which said, "I am the treating physician. This is the patient. In my professional opinion, the patient needs this treatment."
The doctor's appeal was denied. A second letter was on the way to the employer/insurer, to launch a second appeal. When Tina called me, the employer's position was: "We won't consider this second appeal until August 24, because the Regional Appeals Committee doesn't meet until then."
Michael's surgery was scheduled for August 20.
I said, "Stop that second appeal. With a self-funded plan, you only get two appeals. After that, it's the Federal District court for you -- good luck with that. Stop the presses, we are going to write a proper appeal."
How much does the CEO make?
When I take on a case, the first thing that I do is to find the highest-level executives of the insurance company -- and of the employer, if it is a self-funded plan. Names are power, access is power, personal contact information is power.
I found the top executive at St. John Health, the Catholic non-profit hospital. In the process, I discovered that there is a higher authority. I am not referring to a divine power, but to Ascension Health Ministries.
The mission of Ascension Health Ministries: "We commit ourselves to serving all persons, with special attention to those who are poor and vulnerable." The highest-level executive at Ascension Health Ministries is Anthony Tersigni. Last year, Anthony Tersigni earned $3.7 million.
Ascension Health Ministries closed three of their less-profitable hospitals in inner-city Detroit during 2008.
The motto of Ascension Health Ministries? "Healthcare that leaves no one behind." Tina Beitel has worked for St. John Health for nineteen years. They must have missed someone, because they were about to leave her husband behind -- by denying the only treatment that could save his life.
Next, I went looking for the head of Blue Cross Blue Shield of Michigan. Blue Cross Blue Shield of Michigan is also a non-profit.
BC/BS of Michigan raised their group rates this year by 22%. They applied to raise the rates on individual policies by 56%. The president of BC/BS of Michigan is Daniel J. Loepp. His total compensation last year was $2.9 million.
In the process or writing and winning forty-four lifesaving appeals, I have developed a high appreciation for the absurd. However ... the irony of this one made my teeth ache.
My goal was to sit here in Seattle, in my worn-out pajamas, and to craft a document that would have Anthony Tersigni running for his checkbook.
How much does the doctor make
The doctor in this case is the surgeon who brought me back from the brink of death four years ago; his name is Dr. Paul Sugarbaker. He has performed over 1500 of these twelve-, fifteen-, twenty-hour surgeries. He has published over seven hundred medical journal articles documenting every aspect of this treatment -- including his outcomes -- over a period of twenty-nine years.
Dr. Sugarbaker pioneered the surgical techniques whereby the surgeon removes every bit of tumor down to 2.5 mm. Then, he treats the remaining microscopic cells with heated intraperitoneal chemotherapy for two hours, making sure that every surface is contacted.
I had metastasized appendix cancer. This same treatment could achieve exponentially better outcomes for people with colon cancer and ovarian cancer. People often ask, "Why aren't more surgeons learning how to do this? Why don't more surgeons want to do this, if it saves more lives?"
Why? Insurers hate to pay for it. Hospitals do not like to book such long surgeries, because four five-hour surgeries are more profitable than one twenty-hour surgery. Besides, who would want to work that hard? A surgeon who performs twenty-hour surgeries for thirty years will eventually look like Dr. Sugarbaker -- stooped, with a visible "widow's hump," and permanently listing to one side.
A surgery of such magnitude requires a long hospital stay, with expensive post-operative care. The only thing to be gained from it is better outcomes for patients.
Dr. Sugarbaker is either at the hospital, or out teaching and demonstrating surgical techniques -- all week, every week, sixty hours a week. He rides a bike to work, he has a small office in the doctor's office building, his minimal staff work tirelessly to get insurance companies to pay for this treatment.
How much does Dr. Sugarbaker charge for performing this grueling surgery? $25,000.
And, even when insurers do grudgingly agree to pay for it, they have many ways of reducing reimbursement after the fact. Although Dr. Sugarbaker may bill $25,000, he never actually receives $25,000. Believe it or not, there are bean-counters in an insurance company office who review the surgeon's bill, crossing off line items as "not necessary." When the deleting and bundling of codes is done, he has received as little as $400 for one of these surgeries. Who would want such a life?
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Anthony Tersigni, $3.9 million. This equals one-hundred fify-six grueling twenty-hour surgeries, at $25,000 per life saved.
I have never been so motivated to win an appeal. As I researched and wrote, I would say to Tina, "Wait till Mr. Moneybags gets a load of THIS."
It took me three days to craft my War Documents. After I faxed and emailed it to all of the top executives in the middle of the night, Tina worked the phones, "Did you receive my urgent, expedited appeal?"
Eight days after Tina and I first spoke, the denial was overturned, and the treatment for Michael was approved. That was August 13. They flew to Washington, D.C. on 8/17, and Michael had his surgery on 8/20.
Gee, I guess that they really didn't have to wait until 8/24 for the Regional Appeals Committee to meet.
Which brings us back to where we started. Greedy doctors?
If this is all about greed, we will soon have many insurance company CEOs, and no surgeons to save our lives.
Peaceful Insurance Warrior-ing,Laurie Todd
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