Outrage: Man's Health Insurance Is Holding His Liver Transplant Hostage

[xchrom]

http://www.alternet.org/outrage-mans-health-insurance-holding-his-liver-transplant-hostage

In January of this year, Dan Reesor, a deputy district attorney in Deschutes County, Oregon, was diagnosed with liver cancer and inflammatory liver disease. Doctors at the University of California Los Angeles told him the combination was fatal, and that a liver transplant is best way to save his life. The liver transplant waiting list has roughly 16,000 people on it, although the sickest are prioritized. But perhaps the greater hurdle to treatment is the financial cost of the procedure: $1.4 million.

As a county employee, Reesor has health insurance. But while Deschutes County is self-insured, it uses an independent administrator, the Montana-based Employee Benefit Management Services, to review claims submitted from employees. EBMS bills itself as “one of the nation’s premier industry leaders in health risk management and third party administration of self-funded health benefit plans, designing strategies to transform the health and wellbeing of individuals, organizations and communities.” Its internal newsletter paints a happy picture of a company that values its employees, works to promote worksite health, and holds a raucous annual client appreciation event featuring, among other things, rafting and rapping.

But EBMS is fundamentally a for-profit entity designed to save its clients money, and in this case the client is Deschutes County. When Reesor approached EBMS about his liver transplant, they flatly denied it, telling him his transplant was both “experimental” and not “medically necessary.” A doctor working for EBMS apparently derived all this from just reading about Reesor; he never met with him. “Basically he's only seen me on paper. So EBMS hires this one doctor who basically determines whether I live or die,” Reesor told local television station KTVZ.

Reesor and his wife Jo are doing everything they can to get the transplant funded. They have set up a website letdanlive.com that seeks to do two things. First, they hope to fundraise with a GoFundMe account; if they can reach $700,000, Reesor will be placed on the transplant list. Second, they are petitioning Deschutes County's three commissioner board members to require the county insurance to cover the transplant. None of the three commissioners replied to request for comment from AlterNet, and have declined to comment to local media.

[merrily]

1. The insurer is Deschutes County government.

The private administrator is getting paid by Deschutes County and and therefore very likely taking its cues from Deschutes County. However, this man has to appeal to Deschutes County to require the administrator to okay payment by the insurer, which is Deschutes County.

On the other hand, the Deschutes County commissioners are ultimately answerable to voters, so maybe publicity for this story will get them to do the correct thing.

As a point that is only tangentially related to the OP article, I am not so sure that the sickest people always get first priority on liver transplants, as the article states.

As with so many things, there seem to loophole ways for the wealthy to get to the front of the line.

[Downwinder]

2. Deschutes County hires a for profit death panel?

Wonder what percentage of the 1.4 million EBMS gets for saving the County money.

[the_sly_pig]

3. Doctors and surgeons that...

remain silent are compliant. They violate their hippocratic oath.

[Enthusiast]

4. Kicked and recommended!

Thank you, xchrom.

[Ilsa]

5. You know, if i had a death sentence handed to me,

and I knew who was responsible, I might would take matters into my own hands if i knew the surgery wasn't going to happen.

[NewOnSite]

6. They are an infection like

Insurance zombies.

[velotresvite]

7. Perverse Financial Incentives Drive Perverse Decisions

As a former US physician who has now moved to Canada (where they have a more rational single payer health care system), I can see how the perverse incentives drive this. Everyone is doing what's rational and reasonable from their own perspective:

1. The county in OR wants to pay as little as they can for health insurance for their employees, so they buy inexpensive insurance.

2. The insurance company, to offer low premiums and still make money for shareholders, has to limit benefits and hires EBMS to limit pay-outs.

3. Because of reduced payments by insurance companies and government payers, the hospitals actually lose money on most patients they see. They need to make this up by charging a high price on the few procedures they perform that few others can do (known as carve outs).

4. The hospitals do need to make money because they have to build new buildings so they can compete for more patients with good insurance - the only way they can stay afloat. They also need to make money to hire the army of insurance relations people who can fight the army of people that the insurance companies hire to deny payments and not pay what is expected.

Most of these issues are solved by a single payer system. In Canada, everyone is covered for health-care so employers are not expected to provide coverage. Benefits and payments from the province are clear and reliable. Hospitals don't compete for patients because there isn't excess capacity - there are plenty of patients for the number of beds. So they don't waste money competing with each other.

But so many people make so much out of the current system in the US, I'm afraid there is little hope for change.

[spinbaby]

8. +1

Welcome to DU.

[BrotherIvan]

9. Excellent post

Thank you for laying it out so clearly.

[JEB]

10. Thanks for the informative and thoughtful post.

I'm pretty sure the guy in Oregon is dead meat. Sometimes here in the States money trumps life.

[Wella]

11. You demonstrate how perverse incentives create great evil

/

[mythology]

12. As somebody facing a life altering, although not life saving surgery

I can't imagine what he's going through. I've broken down crying several times over a surgery that isn't lifesaving but will cost me 18 months of recovery and that's with a very highly rated insurance company that approved my surgery in less than a business day after I met with my surgeon.