HOSPITAL REJECTS INSURER'S PLAN FOR CANCER TREATMENT PAYMENT

Blue Cross and Blue Shield of Missouri proposed a plan in August to fund part of the cost of a bone marrow transplant for Cape Girardeau resident Mike Carlton.

The plan called for the insurer to pay a total of $100,000 over a five-year period, with essentially installment payments predicated upon Carlton surviving.

But officials at St. Louis University Medical Center and Dr. Gary Spitzer, the medical center doctor who would perform the procedure, strongly rejected the proposal.

Peter Clay, a senior vice president with Blue Cross in St. Louis, said in an Aug. 24 letter to Spitzer and the medical center that such treatment for multiple myeloma, a cancer of the white blood cells, was not covered by Carlton's group health plan because it was considered experimental.

A firefighter for the city of Cape Girardeau, Carlton is covered by a health plan as are all other city employees. Medical professionals involved in Carlton's case and Cape Girardeau city officials argue that Blue Cross should pay for the transplant.

Although Blue Cross contended Carlton's proposed treatment was not covered by insurance, Clay said in the August letter that the insurer recognized as spelled out by Spitzer that there was a better chance of success in Carlton's case because it would involve transplanting bone marrow from the patient's identical twin brother.

Blue Cross proposed that upon Carlton's admission to St. Louis University Medical Center, the insurer would pay the hospital $20,000.

"BCBSMO will make an additional $20,000 payment at the end of each year for four consecutive years so long as Mr. Carlton survives," Clay wrote.

"If Mr. Carlton should expire during the payment period as a result of a condition related to cancer, a complication of cancer, the treatment or complication of the treatment, our obligation for payment would end," explained Clay.

He said Blue Cross officials felt the hospital should have to share in the cost of what the insurer considered an experimental treatment.

The proposal, however, was flatly rejected in a meeting with hospital officials in early September. "They called us unethical, immoral, and told us to get out," recalled Clay.

Clay said premiums paid by Blue Cross subscribers do not include fees for treatment and care considered to be investigational.

Blue Cross is the largest health benefits financing company in the state, providing health coverage in the city of St. Louis and 84 Missouri counties.

In the fiscal year ending Dec. 31, Blue Cross processed 4.8 million claims and issued claims payments totaling $627.3 million, company officials said.

St. Louis University Medical Center officials said they were opposed to the Blue Cross funding plan because it was based on years of survival for the patient.

"What we were unwilling to do is receive reimbursement on the basis of years of survival. To assign a monetary value to someone's years of life is inappropriate," said Jan Blomefield, administrator for transplant services at the hospital.

"Whether a procedure is considered experimental or proven, no one can be absolutely positive what an outcome will be," she said.

Blomefield said she had never heard of such a proposal before.

"How long could a hospital remain financially solvent if we got paid a little bit each year?" she asked.

"The concept of paying based on years of survival is going to set back the way we do medicine," she maintained.

Blue Cross, said Blomefield, has wrongly portrayed the hospital as unwilling to share the financial cost.

"They made it look like we were the bad guys, unwilling to negotiate or help out or anything," she said.

But she insisted the hospital was willing to share the financial risk, but not based on how long the patient survives.

"They want us to guarantee the outcome," she said. "If we were getting reimbursed based on his survival, every time that patient got a sniffly nose, we would bring him back into the hospital."

Spitzer said that under such a plan, doctors would be encouraged to only treat those patients that are the healthiest.

"It's an insult to us trying to practice medicine," he added.

Blomefield maintained that the proposed transplant procedure is not experimental. She pointed out that some other insurers do pay for bone marrow transplants for multiple myeloma patients.

She said the hospital has performed a number of such transplants on multiple myeloma patients, who have gone in with less of a chance for success than Carlton.

"Even Missouri Medicaid pays us to do this type of procedure, as well as many other commercial insurers," she said.

The St. Louis hospital does about 150 to 200 bone marrow transplants a year in treating a variety of cancers.

In addition, Spitzer is a leading expert on such transplants, Blomefield said, suggesting that having an experienced physician handling the procedure should be considered by Blue Cross.

"We can't promise Mike that this is going to be successful, but he has every factor that could be positive on his side," she said.