For teacher with cancer, insurance company calls the shots

There’s a war going on inside the brain of 26 33-year-old Sioux Falls, S.D., school teacher Katie Blunck.

Cancer cells in her brain are fighting healthy cells.

“It’s very aggressive, hard to kill and considered incurable,” Blunck tells the Argus Leader.

The war might kill her; so might the one she’s having with her insurance company, which is refusing to pay for proton therapy, which is what doctors at Mayo Clinic are recommending as a way to kill the cancerous cells without harming healthy brain cells.

Twice now the insurance company — Wellmark Blue Cross and Blue Shield — has said it’s “not medically necessary.” So doctors are requesting it again, saying it is. If the third appeal is denied, there can be no more.

The insurance company says there’s not enough data to say the treatment will work. “You can’t get research/proof if you don’t actually use it on people to gain proof/research/information,” she writes on a GoFundMe page. “They have to start somewhere so they should start now …. and here I am. Let’s get going on this—time is a-tickin’!”

She says she’s feeling special, because there are only five people in the United States being treated for this type of cancer, all of them at the Mayo Clinic in Rochester.

“One woman got it when she was 30 and now it is back again and at the age of 40. Another 17-year-old girl in the pediatric oncology department was just diagnosed, too,” she said.

“The insurance company will be as they will be, and things will go as they will go,” she tells the paper.

She’s focusing on the box of cards she’s gotten from students, now that they know she won’t be back this school year. “But to know that I have so many people rooting for me … this outpouring is so amazing.”

She’ll be paid at least through the end of the school year because other teachers and staff have donated their own sick time once the 30-days allowed by the school district runs out.

  • MrE85

    Insurance companies call the shots for just about all of us, I’m afraid.

    • No pun intended?

      • MrE85

        I’ve worked in the health care/insurance field for more than 30 years, and I can tell you that I have no better understanding on how to navigate the process than anyone else. Like many my age, I’m struggling to figuring out I can find coverage in the gap years between retirement and Medicare eligibility.

        • I was referring to this:

          “Insurance companies call the shots for just about all of us”

          But yeah, this whole health insurance mess is infuriating.

          • Jack

            Wish that flu shot would have worked better. But at least insurance covered. Still waiting on the bill for the call the doctor versus office visit.

    • theoacme

      I bet the insurance execs wish that they could legally shoot Ms. Blunck with a couple hundred AR-15’s, as well as anyone else who has the audacity to object to their treatment of her and everyone else who ever gets ill and needs to claim from their health insurance company…

      …given President Trump’s reactions to the Parkland shootings, probably Paul Ryan will propose legislation soon that will allow exactly that, and I Daudt that Kurt would object.

  • Ralphy

    A health care system that assumes the insurance company bean counters have more medical expertise and specific case knowledge than the doctor treating the patient is way past broken.
    Her likely only options are to die or go bankrupt with uninsured treatments.
    Tragic.

    • MikeB

      Need to take for-profit insurance out of health care. They have handed her a death sentence.

      • BJ

        I’m not sure if this Blue Cross is a non-profit, they all used to be Non-profits, but that changed in the mid 90s. Some are and some are not.

    • Jerry

      Who knows more about medicine? An accountant or a doctor?

      • RBHolb

        Except that the question the company asks is “Who knows more about turning a profit?”

      • Jack

        Let’s kick that up a few more rungs on the hierarchy. It’s the tone at the top (C Suite) that is driving these decisions, not the accountants.

        See my note above about humans with souls.

  • Jerry

    Remember how the complaint about socialised medicine is that people didn’t want bureaucrats deciding your healthcare, like it wasn’t already happening?

    • Brian Simon

      They’re not goverment bureaucrats, so its ok.

    • RBHolb

      Deciding who can get potentially life-saving treatment is so not a “death panel.”

    • Lindsey

      It’s even worse than a death panel, as these decisions are all about money.

    • fromthesidelines21

      My dad, who had MS, was once denied a power wheel chair because the insurance company didn’t feel it would ‘improve his quality of life enough.’ I’ve never gotten over how disgusting the notion of a profit motivated panel deciding what would or wouldn’t improve someone’s life.

      • John O.

        And the decision was made by a person who probably had zero medical background (other than binge-watching “Grey’s Anatomy”).

        • I assume their medical panel is made of people with degrees in medicine.

          • Wayne

            Or an algorithm…

            This is becoming more and more common as companies try to leverage big data and machine learning.
            And, regardless of what any sales person says, algorithms are made by people and can be just as human as the rest of us in there capacity for cruelty.

          • Jack

            There are no people left actually looking at much of anything. The push is to automate everything and let algorithms made the call.

            Argh….. The world was better when actual people with souls were in charge of making decisions.

      • Ralphy

        My daughter’s SO has MS.
        He was hit by an unemployed, uninsured motorist with a revoked license while in a crosswalk.
        Broken leg.
        Broken chair.
        Leg with a plate and screws.
        Broken chair.
        The chair is not old enough so his insurance and Medi-Care have both turned him down. He was told it is the responsibility of the driver (again, unemployed, uninsured with a revoked license).
        His lawyer assures him that A) he will win a judgement and B) he has two chances of collecting. No chance and not a chance.
        He has applied for help from the victim restitution fund. That will take several months and only cover about 25% of his medical and chair costs.

        • His own insurance should cover expenses from an uninsured motorist. Or is he looking for compensation for missed work?

          • Ralphy

            You would think so.
            They have “ruled” that his 2 year old chair has not reached the end of its service life, so they have denied his claim. As did Medicare.
            He does have a lawyer working for him, but no resolution.

  • Guest

    Only 5 in the US have this. To move from experimental to mainstream takes proof.

    Insurance does not cover “everything that might help”, it covers what has been known to work.

    It is no surprise those on the early edge of new approaches have to go toward mainstream without insurance company money.

    I think that is a proper role for government…..to say it does or does not meet the standards of care for all insurance companies.

    • jon

      //Only 5 in the US have this.

      I’m not sure what you mean by that statement… it looks like PBT has been used a significant amount in the US, it’s not common, but wikipedia lists out facilities that offer the treatment, and there are more than 5…
      https://en.wikipedia.org/wiki/Proton_therapy

      What I’m not clear on is the cost difference between that and more conventional (and from what I’m gathering in this instance, perhaps fatal?) therapies… and from wikipedia (which admittedly seems out of date on the topic) sounds like the price might actually be cheaper than conventional therapy, at least for the newer PBT tech…

      So while I’ll admit I’m not in possession of all of the fact here, it seems like insurance companies should be clamoring to get cheaper more effective treatments, and if they have to put some money into the pot to get them seems like it could be a worthwhile investment.

      • Nicholas Kraemer

        I think they meant only five people have the same type of cancer.

        • Lindsey

          That’s actually the main problem with cancer treatment. Each cancer type is different and each person’s individual cancer can be different as well (caused by a different mutation, genetics, exposure, etc). One size fits most does not apply to many cancers.

          • I would presume that’s the thinking of the Mayo Clinic doctors.

          • Lindsey

            That’s why you go to Mayo. If you have a more standard cancer, choose any oncology practice and you’ll be fine. But, if you are one of five, you are going to need a specialist.

    • Brian Simon

      One question is whether insurance companies should participate in experimental therapies with the goal of lowering long term costs. It may seem expensive to pursue an experimental therapy for one patient, but if it’s effective, perhaps there are long term cost justifications. But do they think that way? I suspect not.

      • Guest

        Experimental therapies would be paid by all of us. Insurance companies are merely gathering claims and dividing by folks to get premiums. IF folks are willing to pay for un-proven therapies for everyone…..who gets to decide THIS un-proven therapy is valid, that one is snake oil.

        Do we cover EVERY therapy before being proven?…..IF so I have tea I want all insurance companies to pay for until you can prove it snake oil.

        There are complicated questions all around with folks lives and families at stake. See Thalidomide.

        • Proton therapy isn’t experimental.

          http://www.proton-therapy.org/insurance_strategies.htm

          • This seems to be focused on prostate cancer. Brain cancer treatment might be considered experimental while prostate cancer treatment might be more widely accepted. This seems similar to denying payment for prescription drugs that are to be used “off label” for a different condition than the one usually treated by that medicine.

          • No, not at all. Mayo’s proton beam program is aimed (no pun intended) at patients with cancers in critical areas.

            https://www.mayoclinic.org/departments-centers/proton-beam-therapy-program/sections/overview/ovc-20185491

          • I was referring to the website link, but yes, I agree with Mayo’s interpretation of the therapy outside the use for only treating prostate cancer.

            However, the insurance company is likely to push every possible interpretation of usage that circumscribes therapy they don’t want to pay for.

        • DavidG

          There’s a whole process that treatments go through to identify potential treatments before they even consider testing them out on people.

        • jon

          The consumer always foots the bill.

          If a hospital funds a clinical study they are doing it with money they get form patients, which the patients get from insurance, if a public university funds it they are doing it with taxpayer money, if a private company pays for their own clinical study on their own therapy, we pay for it when they sell that therapy if it’s successful for a higher price, or we pay for it in a higher price for their other therapies, which of course are paid for by insurance again…

        • John O.

          A therapy that is considered “proven” was once upon a time “unproven.” Some patients took those first treatments that were paid for somehow.

          My spouse also has a rare sarcoma that is stage 4. Our Mayo oncologists have been able to (so far) contain the growth of her many tumors by repurposing a relatively inexpensive drug. Pill therapy too; no ports, pumps or intravenous cocktails. That’s the sort of thing Mayo research brings to the table. If this treatment loses its effectiveness, then we are back where this woman and her family are. “Gee-whiz” therapies don’t always have to be “new” by default.

          • As near as I can tell, all proton beam therapy does is target radiation to specific locations rather than just blasting everything in sight, killing the good and the bad.

          • John O.

            Fortunately, I have not had to educate myself on that particular treatment. And I pray that I never have to.

  • >>Wellmark Blue Cross and Blue Shield — has said it’s “not medically necessary.”<<

    Except, you know, to live…

    /F*ck cancer
    //Brain cancer killed my father.

  • Jeff

    I have a lot of sympathy for her. My wife died of breast cancer 21 years ago. She spent a lot of her time battling the insurance company for a promising treatment, a stem cell transplant, which was working for other types of cancer. I don’t remember the details but she eventually wore them down and they found a research program she fit under. Alas, the treatment never panned out. However, she was young with children and it seems to me that should count for something even if it’s experimental.

  • Karl Crabkiller

    I showed this article to my neighbor, he is an oncologist in Vancouver Canada (which has universal health care). He said proton cancer treatment is available in very specific types of prostrate cancer – government insurance would not cover proton therapy for brain cancers. A patient would have to travel outside Canada and pay for treatment.

    • So finally, America has a system identical to Canada.

      • jon

        Woot! Break out the mission accomplished banners! We did it!

  • AmiSchwab

    isn’t america great?

  • Tyler

    Death panels, indeed.