HACKENSACK, NJ-- Tough economic times can be blamed for the current game of roulette played by health-care insurers when it comes to coverage of experimental or off-label treatments, said Grace Powers Monaco, JD, director of the Medical Care Ombudsman Program, Medical Care Management Corp. Bethesda, Md. But overeager physicians, patients, and patient advocacy groups must also share some of the blame for the current tug of war, she said.
Independent reviewers, such as Medical Care Management Corp., can often help resolve disagreements (see below). The company provides case review services for employers, insurers, and managed care plans on a fee basis, and pro bono for patients who cannot afford to pay. Ms. Monaco is also founder of the Candle Lighters, an advocacy group for parents of children with cancer.
The problem goes back to the early 1980s, when the federal government stopped including patient support care costs in grants for studies of new therapies, she said at a conference, sponsored by the Northern New Jersey Cancer Center, Hackensack Medical Center.
By 1986, she said, payers realized that patient supportive care costs were being passed on to them. They responded with more rigorous enforcement of exclusion clauses, especially regarding autologous bone marrow transplantation (ABMT) for adult lymphoma patients and later for breast cancer and other indications.
Compounding the problem, Ms. Monaco said, was the tendency by some physicians to oversell the case for ABMT. The media picked up the story, and patients, many of whom were medically ineligible, begin clamoring for transplants.
Unfortunately, some patient advocacy groups may be exacerbating the situation, she said, "by always assuming that the patient is right." As a result, physicians and patients may be at cross purposes with each other," she said, pointing to cases in which patients have inappropriately sued physicians for not providing experimental care (see the first case history ,below).
Some physicians, perhaps out of fear of such lawsuits, have lacked the courage to deny patients' requests for inappropriate treatments, Ms. Monaco said. When the decision is made to go forward with a costly experimental treatment, instead of facing economic issues head-on before treatment, physicians may take the ostrich approach: "Let's just bill the charges and see if they will pay for it."