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HealthWatch: Cancer Patient Says SF Hospital Denied Insurer-Approved Care

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St. Mary's Medical Center in San Francisco. (CBS)

St. Mary’s Medical Center in San Francisco. (CBS)

CBS SF Bay (con't)

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SAN FRANCISCO (CBS 5) — What if you have a serious illness and your health insurer authorizes treatment that may prolong your life, only to have your care denied by the hospital? Christine Stryker, a college professor and mother of two, said it recently happened to her.

Five years ago, Stryker was diagnosed with advanced melanoma. The cancer has now spread to her liver. Her prognosis is very poor and she’s running out of time.

“I know that things are getting worse and you know time is of the essence right now,” said Stryker.

But a new drug called Yervoy is sparking real hope. Doctors said the treatment, an immunotherapy, allows the body to better recognize attack and kill cancer cells.

Stryker said, “It does mean probably life or death if it works.”

“For this patient, it’s basically her last hope,” said melanoma specialist Dr. David Minor.

When Stryker showed up at St. Mary’s Medical Center in San Francisco to get her first dose, she was stunned. She said the hospital refused to treat her.

It’s not because Stryker doesn’t have health insurance. A letter provided to CBS 5 detailed how her insurer Blue Shield authorized the treatment. St. Mary’s also takes her insurance.

Stryker and her doctor both said St. Mary’s is an in-network hospital and has a contract with Blue Shield to take patients such as Christine. CBS 5 asked St. Mary’s about the case, but the hospital won’t talk about it.

Minor is Stryker’s oncologist. He told CBS 5 that he has never had an in-network hospital refuse to treat a patient. “This is really unprecedented,” Minor said.

The oncologist said he spoke to the head of St. Mary’s Medical Center for an explanation. “The hospital refuses to give the treatment because they say under their contract they are going to lose too much money,” Minor said.

Minor said the CEO told him how St. Mary’s can only bill Blue Shield up to $19,000 a day per patient. But a single dose of Yervoy costs the hospital more than $30,000 and Stryker was scheduled to get four treatments. “And, they said that was too big a loss,” said the oncologist.

And while the thought of a hospital denying authorized care to a cancer patient seems unthinkable, medical bioethicist Dr. David Magnus of Stanford University is not surprised.

“This is the tip of the iceberg,” said Dr. Magnus, who said the U.S. health care system is broken and that it won’t take too many of these kinds of drugs to make all hospitals go broke.

“Those are absolutely conversations that are taking place at every hospital. Every hospital that treats cancer patients is going to have to be looking really hard about what they’re going to offer and when,” Magnus said.

Magnus is seeing a growth in incredibly expensive treatments that he believes offer modest benefit, like Yervoy. The FDA approved the drug last year for patients such as Stryker.

“If you look at the data, it extends life by an average of 3.6 months at a cost of over $120,000″ said Dr. Magnus.

Related Links:
Yervoy Clinical Trial – Study
Yervoy Clinial Trial – Editorial

Bristol-Myers Squibb, the drug’s maker, told CBS 5 in a statement, “Yervoy is appropriately priced based on the innovation it represents and the value it brings to patients.”

While the average benefit is nearly four months when compared to the control drug, an oncologist involved in the trial believes that benefit is actually a big benefit. Not only that, the study showed how some patients live years longer.

“And of course that’s what we hope to achieve with this patient.” Minor said.

However, at present, there is no way to predict an outcome. Stryker was treated with Yervoy at a different hospital. But her doctor said the drug probably did not work. Her cancer is still growing.

Even so, Stryker said she had the right to get it. “Especially if you’ve been fortunate to be insured in the system that we have now this kind of thing really shouldn’t happen,” said Stryker.

She said she hopes a new treatment comes along soon, before it’s too late, and that a hospital will let her in.

(Copyright 2012 by CBS San Francisco. All Rights Reserved. This material may not be published, broadcast, rewritten, or redistributed.)

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