THE BLOG

Red State Lawmakers Helping Cancer Patients Push Back Against Insurance Denials

03/23/2015 10:34 am ET | Updated May 23, 2015
BitHead/Flickr

The lawmakers who wrote Obamacare devoted more attention to insurance companies than to any other part of our healthcare system. That's understandable considering the countless stories members of Congress had heard over the years from their constituents, especially those with cancer.

Many of them told of being deemed "uninsurable" by insurance companies because of a preexisting condition. They couldn't buy a policy at any price. Many others complained of having doctor-recommended care denied by insurance company executives who had never seen them or even talked to them.

Republicans and Democrats alike were stunned when they learned of a widespread industry practice of canceling women's policies immediately after a cancer diagnosis. They learned that several Blue Cross plans used a computer algorithm that automatically targeted every policyholder who had been diagnosed with breast cancer. Another insurer even paid bonuses to employees who exceeded policy cancellation goals.

Even Republicans who have vowed to replace Obamacare have said they would keep many of the law's patient protections. "We would protect people with existing conditions," Republican Reps. Paul Ryan, John Kline and Fred Upton wrote in a Wall Street Journal op-ed earlier this month.

There is growing evidence, however, that despite the protections, insurers are finding new ways of limiting or denying access to needed care. Last summer, more than 300 patient advocacy organizations sent a letter to Secretary of Health and Human Services Secretary Sylvia Burwell expressing concern about new tactics insurance companies have implemented to avoid paying for treatments and medications that many sick policyholders need.

"We are increasingly aware of evidence that new enrollees, especially those with chronic health conditions, are still facing barriers to care," they wrote. One group, the Leukemia and Lymphoma Society, said it found health plans in several states that charged patients with blood cancer as much as 50-percent co-insurance rates.

Several insurance companies have also told cancer patients across the country that they will not cover a form of radiation therapy recommended by their doctors despite the fact that, unlike more traditional treatments, it significantly reduces damage to healthy tissue and critical organs.

The therapy, which uses proton beams, has been approved by the Food and Drug Administration and is covered by Medicare, but some insurers have refused to cover it, saying they haven't been convinced that it's as cost-effective as other forms of radiation. Several physician and patient groups have countered that it is both cost-effective and less harmful, noting that many studies have shown that proton therapy spares normal tissue and reduces short- and long-term side effects and secondary cancers.

Legislators in a number of states, including Oklahoma and Tennessee, have introduced bills that would require insurers to cover proton therapy if a patient's doctor believes it is the most appropriate form of radiation.

The Oklahoma legislature is considering a bill that prohibits health insurers from holding proton radiation therapy to a higher standard of clinical effectiveness than any other radiation therapy treatment. The House approved the measure 97-0 earlier this month as many cancer survivors who had had proton therapy treatment watched from the House gallery.

Legislators in Tennessee are taking a somewhat different approach. The bill being considered there -- the Cancer Patient Choice Act -- addresses insurers' concerns about cost. If enacted as written, cancer centers in the volunteer state will not be paid more for proton therapy treatments than for other forms of radiation covered by insurance. The bill also establishes a mechanism to collect more data about the cost and clinical effectiveness of proton therapy.

A driving force behind the bill is Don Denton, a Christian conservative businessman and prostate-cancer survivor from Townsend, Tennessee.

Denton said he knew that if he had agreed to the treatment favored by his insurer, he likely would be incontinent and impotent "and awaiting the very real possibility of the cancer recurring." After weighing alternatives, he chose proton beam treatment, and he's grateful he did. He said he not only is still cancer-free but has had no permanent side effects or quality-of-life issues.

Denton now heads the Tennessee Cancer Patient Coalition, a group that believes patients and their physicians, not insurance companies, should make medical treatment decisions. A poll conducted by the coalition last week showed that 92 percent of Tennesseans believe doctors should have the final say on the best treatments for cancer patients. Eighty-four percent said insurance companies should be required to cover medical treatments that offer a cancer patient the least risk of complications.

Lawmakers on both sides of the political aisle, in Washington as well as in state capitals, campaign every election cycle on making health care in this country more patient-focused. They tell prospective voters that neither insurance company bureaucrats nor government bureaucrats should be making treatment decisions. And they all pledge to restore the patient-physician relationship.

But when they're presented with opportunities to do just that, many of them parrot one of the insurance industry's favorite talking points: that the government shouldn't be telling insurers what to cover.

The bill Denton's group supports should assuage the concerns of legislators concerned about government overreach and even lobbyists for the insurance industry. The sponsors of the bill note that it establishes parity among the various radiation therapy options available to cancer patients. This means there will be no cost increase for patients, their doctors or insurers.

So not only does the bill go a long way toward restoring the patient-physician relationship, but it is also a win for insurers. They will have what is essentially a guarantee that the cost of proton treatments for cancer patients will not exceed the cost of other forms of radiation.

Cancer patients in Tennessee and across the country will be paying close attention to what lawmakers in Nashville do in the coming weeks. If they vote against the Cancer Patient Choice Act, they might as well be saying they have no problem with insurance company bureaucrats making life and death decisions.