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Blue Shield to Cover Experimental Breast Cancer Treatment : Insurance: Company says continuing threat of lawsuits was key factor in decision. Other insurers have also eased restrictions.

January 19, 1995|DAVID R. OLMOS | TIMES STAFF WRITER

Faced with lawsuits and intense pressure from women seeking coverage for a controversial breast cancer treatment, Blue Shield of California has announced that it will begin paying for the procedure for the first time.

Blue Shield has come under sharp criticism from breast cancer advocacy groups for its blanket policy of refusing to reimburse members for the experimental therapy: high-dose chemotherapy in conjunction with bone marrow transplantation. Blue Shield, one of the state's largest managed-care companies, with 1.5 million members, said it now has specific guidelines for coverage of patients who meet certain eligibility requirements.

With the policy change, Blue Shield joins other major insurers nationwide who, spurred by several highly publicized lawsuits, have moved to pay for the treatment. Six months ago, a Los Angeles County Superior Court jury awarded $312,000 in damages to a Tustin woman who sued Blue Shield for its refusal to pay for a bone marrow transplant to treat her breast cancer.

L. Susan Slavin, a Hempstead, N.Y., attorney who founded the Breast Cancer Legal Advocacy Project, said national Blue Shield and Blue Cross associations generally have been "the most intractable" about reimbursements.

The controversy over the bone marrow transplants goes to the heart of a dilemma in health care: When should insurers have to pay for experimental drugs, treatments or technologies? Bone marrow transplants are routinely used to treat such diseases as leukemia, and the procedure is being used more frequently for breast cancer. But most doctors consider the therapy experimental, and many insurers have refused to pay for it on that basis.

In announcing its new program, Blue Shield said it has not changed its policy that the treatment is "investigational" and thus not a standard covered benefit for members. Rather, the company has set up a pilot project in cooperation with four medical transplant centers--City of Hope National Medical Center in Duarte, UCLA Medical Center, Stanford University Medical Center and UC San Francisco Medical Center--and has established guidelines for eligibility.

Blue Shield officials conceded that the continuing threat of lawsuits was a key factor in its decision.

Slavin said insurers nationwide have been paying for the procedure more often, but often only after the threat of a lawsuit. "This procedure has efficacy for breast cancer, and there is no reason for insurers turning it down other than the almighty dollar," she said.

Blue Shield said patients must meet guidelines relating to the progression of their breast cancer, their previous treatment therapies and their medical prognosis.

"If the treatment is recommended by one of these four transplant centers and Blue Shield concurs that it is clinically appropriate based on these guidelines, then we will pay for it," said Dr. Wade M. Aubry of Blue Shield.

The procedure can cost upward of $150,000, but insurers routinely negotiate steep discounts with medical centers in exchange for patient referrals.

Dr. I. Craig Henderson, director of clinical cancer programs at UCSF, praised Blue Shield's initiative but cautioned that the jury is still out on the effectiveness of the treatment.

"It's not at all clear that this treatment provides a survival advantage over other treatments," he said. "Many breast cancer experts feel it is no better than conventional (chemotherapy) treatments, and there are some who feel it may be worse than other treatments."

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