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Is this a healthy way to choose who gets care?

January 20, 2008|DAVID LAZARUS

We've heard a lot from state and national political leaders recently about the need to reform the U.S. healthcare system, and not least to extend coverage to the 47 million Americans who now lack insurance.

But what about those who are fully insured and still struggle for coverage of necessary treatments?

Monica Blumenfield, a longtime employee of the Long Beach Unified School District, is such a person. She was turned down for coverage of physical therapy for work-related nerve damage and for an MRI scan related to earlier treatment for breast cancer.

Her insurer, Blue Shield, said the decisions were reviewed by the company's medical director. But this wasn't a doctor experienced in either physical therapy or oncology. It was a Northern California osteopathic physician who lists his specialty as pulmonary disorders such as bronchitis and asthma.

"The doctor who reviewed my case wasn't qualified to make these decisions," Blumenfield, 50, told me. "Basically, Blue Shield tried to deceive me."

The government reported this month that the United States spent an average $7,026 per person on healthcare in 2006. That's more than double the amount spent in developed countries with single-payer insurance plans (where life spans are longer and infant mortality lower).

My colleague Lisa Girion has done eye-opening work detailing examples of private insurance companies canceling the policies of patients after they're diagnosed with serious (and costly) ailments.

But for every such horror story, there are thousands more examples of insurers denying coverage for specific treatments and leaving patients holding the bag for their medical expenses.

Blumenfield, a school counselor who ran unsuccessfully for a seat on the Long Beach City Council in 2006, had always enjoyed reasonably good health.

That changed in 2002, when she was diagnosed first with Hodgkin's disease, a cancer of the lymphatic system, and then breast cancer.

Blumenfield underwent radiation treatment for her Hodgkin's and had a mastectomy for the breast cancer, followed by reconstructive surgery.

She said this was when she received her first inkling from Blue Shield that her relationship with the insurer had changed. "I got the reconstruction done," Blumenfield recalled, "but there was a lot of demands for extra documentation."

In early 2006, her doctor diagnosed her as having carpal tunnel syndrome, a nerve disorder of the wrists, arms, shoulders and neck frequently associated with computer use. He prescribed physical therapy.

Blumenfield went to a local clinic she'd used after her mastectomy, where her treatment had been covered by Blue Shield. She received several months of physical therapy for her carpal tunnel syndrome and said the treatment not only improved her condition but almost certainly allowed her to avoid expensive surgery.

Several months later, Blumenfield received a letter from Blue Shield saying that her treatment wouldn't be covered and that she was fully responsible for the clinic's $2,000 bill. She appealed the decision.

Early last year, Blumenfield was told by Blue Shield that her appeal had been rejected because the physical therapy was determined "to be not medically necessary" -- despite her doctor's conclusion to the contrary.

Blue Shield said the treatment had been reviewed "by an independent physical therapy specialist."

A separate letter to Blumenfield's clinic, Movement Works Physical Therapy Inc., stated that the treatment was "reviewed for medical necessity by Alan Brooker, D.O., medical director for Blue Shield of California."

Brooker is not a member of the American Medical Assn., according to the organization's website. But the site lists him as a nonmember and identifies his specialty as pulmonary disease, or lung-related disorders.

About a month after Blue Shield rejected Blumenfield's physical-therapy appeal, she received another letter from the insurance company saying it wouldn't cover MRIs related to her breast cancer, even though it had done so without apparent difficulty for the previous three years.

The letter said the scans were considered "investigational or experimental" and as such were "not in accord with Blue Shield of California medical policy." The letter was signed by Brooker.

It was at this point that Blumenfield said she complained to her employer that important decisions involving her healthcare were apparently being made by a doctor with little or no experience in physical therapy or cancer. She asked that he be removed from her case.

Blue Shield declined to comment on specifics about Blumenfield's situation.

Dr. Alan Sokolow, the company's chief medical officer, said doctors who sign off on denials of coverage typically consulted first with specialists.

"We employ a lot of medical directors who have a variety of medical expertise but who rely on the expertise of others trained in a specific area," he said.

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