COSTLY BONE MARROW TRANSPLANTS AT CENTER OF DISPUTE

Bone marrow transplants have been at the center of a health care dispute in recent years over whether insurance companies should pay for such expensive and often risky treatments.

For persons suffering from life-threatening disease and their families, the health care battleground has been littered with emotional and financial scars.

Insurers say there is an economic factor to consider. They say they can't afford to cover every medical procedure, however experimental.

Courts also have entered the picture, deciding in some cases who should pay for such treatments.

About 5,000 bone marrow transplants are performed each year worldwide, and many patients must pay for the operation themselves.

Such procedures can cost $150,000 and up, with much of that cost involving lengthy hospital stays. Insurance reimbursement often determines the setting and type of therapy, one study shows.

Transplants involve long hospital stays as the patient's immune system recovers and new bone marrow grows.

Most insurance plans cover bone marrow transplants for treatment of leukemia, Hodgkin's disease and several other diseases of the blood.

But other diseases, such as multiple myeloma, are often not covered.

Doctors at a recent medical conference suggested that transplants in treatment of multiple myeloma should be covered by health insurance.

Five years ago, former Democratic presidential candidate Paul Tsongas of Massachusetts received a bone marrow transplant for a similar form of cancer.

Mike Carlton of Cape Girardeau suffers from multiple myeloma, which impairs the bone marrow's ability to manufacture blood cells.

For the past several months, he has been battling with Blue Cross and Blue Shield of Missouri over the insurer's refusal to pay for a bone marrow transplant recommended by his doctors.

Carlton has even hired a St. Louis attorney and threatened to go to court to seek an injunction requiring Blue Cross to pay for the cancer treatment.

The insurer has contended its investigational and not a proven treatment.

Blue Cross officials say they must make wise use of their resources. "The insurance companies are not bottomless pockets of money," said Andrew Kelahan of the Blue Cross and Blue Shield Association in Chicago. The association provides guidelines and serves as an informational resource for the nation's 73 Blue Cross companies.

Myrita Holtcamp, director of the consumer affairs division for the Missouri Department of Insurance, said insurers like Blue Cross face some tough decisions.

"They have to make some tough decisions because people expect their policy will pay for everything, but if it did, then they probably couldn't afford the cost," she pointed out.

"It's really emotional and it's hard to be told no whenever you are looking at somebody dying," she said.

Nowhere was that more evident recently than in the case of Angela Davis, a St. Louis television producer and free-lance writer.

In 1988, Davis underwent radiation and chemotherapy after tests showed cancer in her right breast. The cancer subsequently spread to her lungs.

She decided to seek a bone marrow transplant, realizing there was only a slim chance for success.

Dr. Gary Spitzer of the St. Louis University Medical Center put Davis' chances for survival at around 20 percent.

Blue Cross said studies indicate that 5 to 15 percent of all breast-cancer patients die as a result of the transplant treatment itself.

Dr. Randall Treadwell, medical director for Blue Cross in St. Louis, said he wouldn't recommend such treatment at this point even for his own family.

"My grandmother died of breast cancer. My mother had her breast cancer removed," he said. Treadwell added that his sister has just finished chemotherapy and radiation treatment for breast cancer.

"I think, what if my sister or mother's cancer comes back and we go through all of this? I see all the complications and I see the potential good that can happen (from transplants) and I think this isn't proven enough yet that I would recommend they go have it done," said Treadwell.

In Davis' case, Blue Cross refused to pay for a bone marrow transplant. So she hired an attorney and filed suit in federal court to force the insurer to pay.

Last December, she won a court order that required Blue Cross to pay for the transplant. But the insurer was also given the right to subsequently sue Davis to try to recover the costs.

In February, she underwent a painful bone marrow transplant. She developed an infection and was twice admitted to the intensive care unit.

Two weeks after the treatment was completed, her cancer returned. After five weeks in the hospital, she returned home and entered a hospice program.

On July 13, the 41-year-old Davis died at home.

A Blue Cross official said the transplant cost about $240,000.

Even after her death, the dispute with Blue Cross threatened to continue in the courts.

But the insurer decided recently not to pursue legal efforts to get Davis' estate to reimburse it for the costly medical treatment.

Deborah Wiethop, a spokesperson for Blue Cross, said the suit was dismissed after Davis' attorney, Sheldon Weinhaus, withdrew from the case.

She said last week that Blue Cross still could elect to file a lawsuit against the hospital in an effort to recover treatment costs.

Weinhaus said the suit was dismissed by a federal judge in St. Louis on Sept. 25.

From a practical point of view, Weinhaus said, it would have been difficult for Blue Cross to obtain reimbursement from the Davis estate.

He added that it also may be difficult for Blue Cross to recover from the hospital. "The courts are beginning to issue orders telling them (insurance companies) to leave the hospitals alone."

The Davis case has some similarities with that of Carlton. Weinhaus was Davis' attorney and is now representing Carlton.

Spitzer was the doctor for Davis and also has been Carlton's doctor. St. Louis University Medical Center has been involved in both transplant cases.

But Weinhaus said the two cases have some differences. They involve difference diseases and the chances for successful treatment are much higher in Carlton's case, he said.

"In Mike Carlton's case, there is an extremely good chance of success," he said.

"In terms of longevity, those who undergo the treatment live longer. Statistically, they live longer than they would without the treatment," said Weinhaus.

"There will always be failures as in the Angela Davis case," he added.

The attorney said he believes court cases such as the Davis case are becoming less frequent.

"I talk to attorneys throughout the country. In most instances, these cases are settled by the insurance companies paying," he said.

Insurance companies such as Blue Cross, he added, have concluded it's almost impossible to win a court case on the grounds of experimental medical treatment.

"People think they are covered for anything which the doctor considers to be medically necessary," said Weinhaus.

But in reality, that's not what happens. Weinhaus said insurance companies are still seeking a way not to pay for bone marrow transplants. "What they are now doing is changing all policies to particularly exclude most kinds of bone marrow transplants."

While costs for such treatment are high, Weinhaus said costs for extraordinary medical care are small when spread out among a large number of subscribers.

Southwestern Bell, he pointed out, set up an experimental treatment policy for its employees. The cost is only $6 per member per month in the company's six-state region, he said.