Insurance woes

First, you have to fight to get insurance. Then, you’ve got to fight insurance companies to get them to pay for stuff. But I’m not telling you anything you don’t already know.

In January, I wrote about a laid-off Flamingo Hilton cocktail waitress named Ann Walters who was diagnosed with a rare form of cancer. The Hilton, which closed the Flamingo in October, provided its employees with insurance through December. Walters planned ahead, signing up for COBRA and making payments in advance. Still, for a few weeks in January, before her new policies kicked in, she was uninsured. For Walters, who was undergoing chemotherapy, getting expensive CT scans and doling out dough for prescriptions, it was a disaster.

At that point, 58-year-old Ann Walters feared going to the doctor, as she had no way to pay the tab. But then, whew, insurance kicked in, and life was wonderful, again. Right? Nope.

Nowadays, Walters is battling on two new fronts. The first: A new, fast-growing lyposarcoma. The second: An insurance company that won’t cover medication prescribed by her doctor.

When it looked like chemotherapy wasn’t helping, Walter’s doctor decided to try an old drug with a new directive.

You might have heard of thalidomide as a sedative used in the 1950s that caused an array of nasty birth defects when pregnant women used the drug. Lawsuits ensued. Now, thalidomide is out of the dog house, and it’s showing some promise as an effective anti-genesis tool for some types of cancer. But the drug’s pretty expensive—something like $800 a month for the first month, a cost that doubles monthly. And “some promise” for “some tumors” appears not to be enough for Health Plan of Nevada to pick up the tab.

“In such cases as this one, the drug is a very unusual one,” said Dr. Christine Petersen, the chief medical officer for Sierra Health Services, the parent company of Health Plan of Nevada. “There’s no literature that I’ve read about that supports this treatment.”

Petersen says that, while thalidomide has been effective with other types of cancers, like multiple myelomas, she said she hadn’t heard whether it’s useful for the kind of soft-tissue cancer that Walters has. So insurance won’t pay.

Walters appealed the decision. The insurance company sent the appeal out for what it calls an external review. The external review concurred with Petersen’s opinion that the drug hadn’t been proven to be “safe or effective.”

Petersen tried to sound compassionate.

“These cases are very difficult,” she said. “The doctor wants to do everything he can, just as we do. … This unfortunate woman has an unfortunate tumor that hasn’t responded to therapy. There are not many options out there.”

Exactly. Could Walters be part of a clinical trial? Petersen said there’s not a clinical trial going on that would fit her needs.

As I write this, Walters—who received the prescription for thalidomide before Labor Day and wants to get started on the medication—has made a last-ditch pitch to Celgene, the pharmaceutical company that makes thalidomide. The company takes on a few patients for free from time to time. It’s looking like she might get the drug after all. That’s the only part of this story that doesn’t suck.