Monday, August 15, 2005

Lawsuit faults insurer in death

Healthcare rationing? Slow euthanasia via denial of care? An example of the complex systemic dysfunction created by profit-driven MBA's in control of healthcare?

I report. You decide.

Lawsuit faults insurer in death
Philadelphia Inquirer, Mon, Aug. 15, 2005

Sandra S. Lobb, a 57-year-old high school teacher, was divorced, living alone, and killing herself with gin.

Her family urgently wanted to place her in a residential alcohol-treatment program. The family says that Independence Blue Cross rejected that treatment as being "unnecessary" in August 1997 - at a time when Lobb was hospitalized for alcohol related health problems and her doctor strongly recommended that she receive intensive rehabilitation treatment. Eighteen months later, the Kennett Square woman died of alcohol-related causes.

In an unusual lawsuit in U.S. District Court, Lobb's older daughter, Kimberly P. Johnson, the executor of her estate, blames Blue Cross for her mother's death and accuses the giant health insurer of usurping the role of Lobb's doctor in deciding what treatment was "medically necessary" for her.

Lawrence M. Otter, the lawyer who filed the suit, contends that the company, the largest health insurer in the Philadelphia area, engages in the "unauthorized practice of medicine" when it trumps doctors' recommendations for their patients.

Blue Cross denies this:

Blue Cross denies making medical decisions for Sandra Lobb or any of its other 2.6 million subscribers. The company also denies responsibility for Lobb's death. Its lawyers contend that Lobb's doctor never specifically asked for residential treatment, a claim that the doctor emphatically disputes. Blue Cross lawyers are seeking dismissal of the suit, which was filed in May.

I. Steven Udvarhelyi, chief medical officer at Independence Blue Cross, said the company's medical staff does make rulings on what is "medically necessary" in some cases, such as a doctor's recommendation to hospitalize a patient or to prescribe alcohol treatment. He said those decisions are based on accepted medical standards and are made solely for the purposes of insurance coverage, not to dictate treatment.

Yet as we see below, sixty percent of appeals are resolved "in favor" of subscribers. That means that the company is wrong in its denials 60% of the time. Further, if denied, the company relates that a person can "get whatever treatment they want by paying for it themselves." (As most people cannot afford expensive care without destroying themselves financially, this reminds me a bit of the infamous "let them eat cake" line uttered by a monarch who later lost a valuable body part.) That's an insurance company's service attitude? In fact, as below, even that "right" is in question. My question is: who needs insurance companies?

Udvarhelyi said the company provides a three-tiered appeals process - improved since 1997 - for doctors or patients to challenge decisions when coverage is denied, and about 60 percent of appeals are resolved in favor of subscribers.

Further, he said, patients always can obtain treatment when coverage is denied - assuming that they are willing to pay for it themselves.

Otter contends in his suit that subscribers do not have the right to privately pay for treatment ruled medically unnecessary. The suit seeks a court order guaranteeing that right.

A 30-day stay in an alcohol rehabilitation center in the Philadelphia area would cost $7,500 to $13,500, based on current rates cited Friday by several facilities. Sandra Lobb's former husband, Frank H. Lobb 3d, of Nottingham, Chester County, said he and his three adult children volunteered to pay for that type of residential treatment themselves, but were barred from doing so by a provision in the contracts that Independence Blue Cross has with doctors and hospitals.

Finally, the statements I've bolded below are troubling. Do they represent de facto healthcare rationing based on value judgment about the likelihood of recovery from addiction and the "worth" of a human life?

... Sandra Lobb's doctor, Cecile M. Pileggi, of Chadds Ford, also considered the time ripe for treatment because the troubled woman, while in the hospital, acknowledged her drinking problem and agreed to accept treatment.

Pileggi testified in a 2003 deposition that she believed Lobb had a good chance of recovery if she received "skilled care" to stabilize her physical condition and got residential treatment for her alcoholism.

Those services were, theoretically, available under Lobb's insurance."The primary problem here was the alcohol, and that was the priority, to get the alcoholism treated," Pileggi testified.

Doctors at Independence Blue Cross ruled in early August 1997 that only "custodial care" - a service not covered by Lobb's insurance - was appropriate.

Pileggi appealed, declaring in a letter to the insurance company: "Sandra Lobb deserves more than custodial care. She will benefit from a skilled level of care."

The appeal was denied. Marie Hatam, a company medical director, replied to Pileggi in an Aug. 25 letter, saying: "The evidence presented did not establish that a skilled level of care was necessary."

Another medical director, Catherine Dratman, later testified in a deposition that coverage was denied because Lobb's prospect for improvement, based on a review of her hospital chart, seemed "poor."

Lobb was discharged from Chester County Hospital in mid-August and placed in a custodial facility in West Chester.

Two months later, she went home. Blue Cross agreed at that point to pay for an outpatient alcohol program. But after two weeks, the coverage was cut off. Company lawyers said in legal pleadings that Lobb did not appear to be "benefiting" from the program.

Lobb attempted to return to work (as a teacher) but reportedly resumed heavy drinking. She died of alcohol-related complications a little more than a year later. Very troubling, indeed.

Very troubling, indeed.

-- SS