Los Angeles Times
If a hospital is full of COVID-19 patients, shouldn’t you be able to receive urgent care elsewhere, even if it’s out of your insurer’s network?
For Hermosa Beach, Calif., resident David Roe, who is battling Stage 4 colon cancer and requires immediate surgery, the answer from his insurer, UnitedHealthcare, was a resounding no.
“You must receive care from a provider within the network,” the company said in a letter dated March 26.
Easier said than done. UnitedHealthcare wanted the operation performed at Cedars-Sinai Medical Center in Los Angeles, where the insurer could save a buck using in-network medical resources.
However, Roe, 29, said he was informed by a Cedars surgeon it would be too risky having him recover in the hospital’s intensive care unit, which the surgeon said was filled with dozens of COVID-19 patients.
The surgeon advised having the operation performed at USC’s Keck Hospital, which boasts one of the state’s best colorectal cancer surgery teams.
UnitedHealthcare’s response was that if Roe wanted to use an out-of-network facility such as Keck, he could pay the estimated $75,000 surgery bill himself — just as he’d been doing to consult with a Keck oncologist at a cost of about $500 a visit.
“It’s unbelievable,” Roe told me. “I can literally feel the tumors growing. I can hear the clock ticking.”
Thanks to the last-minute intervention of a lawyer and state officials, he’s scheduled for surgery Friday at Keck, and UnitedHealthcare will cover the cost.
But getting to this point has been an obstacle course that illustrates both the extraordinary circumstances of life during a pandemic and the long-standing lunacy of the U.S. health care system.
“I’ve never been so dumbfounded by bureaucracy in my entire life,” Roe said.
He’s insured under a health maintenance organization, which by design keeps policyholders within a rigid network, as opposed to the increased (and pricier) flexibility offered by a preferred provider organization.
Still, exceptions are possible.
“There may be case-specific circumstances that would allow for a referral out of network if the health plan’s in-network provider cannot provide medically necessary care in compliance with the law,” said Rachel Arrezola, a spokeswoman for the state Department of Managed Health Care, which oversees HMOs.
When he received his cancer diagnosis in July, Roe said, he was given about a year and a half to live.
That changed thanks to chemotherapy and treatment to bolster his immune system. The softball-size tumors in Roe’s liver and colon started to shrink.
The Keck oncologist, Heinz-Josef Lenz, co-director of the Colorectal Center at USC’s Keck School of Medicine, determined that a narrow window had emerged in which surgery was warranted to remove the shrunken tumors before they could start growing again.
“If successful,” Roe said, “this could give me years or even decades, rather than months.”
He appealed UnitedHealthcare’s decision. The company refused to budge, regardless of the potential danger of being treated at Cedars.
Duke Helfand, a Cedars spokesman, said he couldn’t address Roe’s situation. But he said the hospital “has capacity to treat COVID-19 patients and those who may need treatment for other serious illnesses, including any who are immunocompromised.”
Roe contacted the Department of Managed Health Care. It too appealed UnitedHealthcare’s decision.
Once again, the insurer said no.
In a last-ditch move, Roe brought in a lawyer, who was able to connect with a top official at the state agency. That official, in turn, reached out to a senior figure at UnitedHealthcare.
And guess what? Once all the layers of stone-faced corporate bureaucracy were bypassed, the insurer reversed course and authorized the surgery at USC.
“We are committed to ensuring that people have access to the care they need during this time and encourage them to contact us to help them meet their needs under their benefit plan,” Maria Gordon Shydlo, a UnitedHealthcare spokeswoman, said in an emailed statement.
If that’s the case, I replied, why did the company reject Roe’s request for urgent out-of-network treatment not once, not twice but three times before agreeing to cover the procedure?
Shydlo said UnitedHealthcare changed its mind “after reviewing additional information we received late last week.”
She didn’t elaborate, but she was presumably referring to the insurer’s discussion last Friday with the lawyer and state official.
Meiram Bendat, Roe’s lawyer, told me no new information was presented during that conversation.
“We laid out the facts as they were already known,” he said.
Roe is now keeping his fingers crossed that his surgery will be successful and he’ll have a life again rather than a death sentence. I’m wishing him well.
But it’s maddening that the richest, most powerful nation in the history of the Earth is saddled with a health care system in which episodes like this are all too common.
An insurance network isn’t some super-exclusive business club. It’s the insurer cutting sweetheart deals with certain health care providers that allow it to save money.
Consumers may benefit from lower premiums, but they may also have to face indignities such as having to switch a prescribed drug to one that the insurer can get more cheaply, or being unable to see a particular doctor or specialist.
Or in extreme cases such as what Roe has experienced, they’re told they can’t be treated at the hospital of their choice, regardless of extenuating circumstances.
Luckily, there’s a solution.
While most Medicare Advantage insurance plans have strict provider networks, traditional Medicare allows beneficiaries to be treated by any doctor or hospital that accepts the program, which is most of them.
A “Medicare for all” system, therefore, would both provide universal coverage and eliminate virtually all coverage networks.
This isn’t “socialized medicine,” as some conservatives claim with sky-is-falling hyperbole. It’s the insurance system already used by nearly every other developed country to make sure everyone’s covered and has access to affordable treatment.
Making the sick fight for adequate care isn’t just exhausting. It’s cruel.
If all goes well, Roe will see our great nation come to its senses and stop making healthcare a struggle for millions of people.
Even if that takes years.
David Lazarus, a Los Angeles Times columnist, writes on consumer issues. He can be reached at [email protected].