Do US insurance companies provide wildly-expensive, mildly-effective drugs to everyone that asks for them? Or do they cap out coverage at a pre-determined maximum, after which you're SOL?
In other words - how is an insurance-based system, with "co-pays" and maximum-treatment caps, better for someone who needs herceptin but hasn't the means to pay for it herself? After all, Herceptin is a drug of last resort as I understand it, and given that, from what other posters here have explained in the past, chronic and severe illness can eat up allowable coverage amounts even on high-premium policies, I can't see how a British woman and an American woman of similar economic means would be in any different situation - except that the British woman can make a case for entitlement based on clinical need and clinical effectiveness to NICE, whereas the American woman has no recourse whatsoever should the insurance company decide her maximum coverage has been exceeded.
I forgot how simple things seem from the outside. Healthcare is much more complicated than that. Firstly, a "denial" isn't final. It never is. The insurer is just one of several players in the game. Every practice has employees whose job it is to get the money out of them. That's what "reimbursement" is about. It's a whole industry in itself, with a complex set of rules and best practices and jargons. They have conventions. It's a career path.
Just because the insurer first says "we don't cover that", or says they'll stop at a particular dollar figure, doesn't mean it's so. Negotiation occurs. The patient doesn't have to do it all themselves. Most of the work is undertaken by their doctor's office, because they're the ones that want the money. There's drug replacement, and appeals. They won't cover x % of x drug? What about the secondary? File for Medicaid. Swing a deal with the insurer. Go through the contract again, not the insurer's contract with the insured, the practice's contract with the insurer. There are financial counselors, there are account reps, their are insurer reps, there are contract negotiators and auditors and things, and that's not even including the clinical people. Healthcare is a huge industry, did you really think that all the paperwork and bureaucracy and offices full of people pushing paper and fighting for money were all on the insurance side? The insurer wants to keep the money. The provider wants to pry it out. From the fact that doctors stay in business it's clear who's winning that war.
ETA:
http://www.herceptin.com/breast-cancer-resources/insurance.jsp proves a point, especially as the drug company pushing this expensive, unproven drug have a whole department dedicated to helping patients fight "denied Herceptin claims"! "Health insurance coverage and reimbursement issues can be confusing and challenging. Herceptin Access Solutions is here to make the process as easy as possible", they say. They even employ "Herceptin Access Solutions reimbursement specialists"! :-O Does that not suggest that desperate, dying US breast-cancer patients demanding herceptin also often face obstacles in getting the drug the advertising (and not the science) has convinc
ed them they need? What was your point again?
Uh, not everybody thinks Herceptin's "unproven". There are hundreds of cancer practices in the US who use it quite a lot, and quite successfully. It's main controversy is because it can damage the heart in some cases, so it's not risk-free. But not many drugs are. Cisplatin works well, but it may make you deaf. There's even one that kills cancer cells but can induce male lactation.
And as for the department for denied claims, that is totally standard. "Denied claims" isn't what it sounds like exactly. It's not final. It's perfectly normal to have people whose job it is to work the paperwork, and explain how to get the reimbursement from the various companies and government agencies. This isn't some sinister thing by the Herceptin people. Every drug company dispenses information on reimbursement to the practices, who use it. Just as every insurer dispenses information to the practices on which drugs they think work and deserve to be covered, and every practice (well, the larger ones) dispense information to the insurers on which drugs they want covered. (I don't think practices are allowed to talk to the drug companies, though, communication there is one-way.)
So, no, it doesn't suggest "desperate, dying US breast-cancer patients demanding herceptin also often face obstacles in getting the drug the advertising (and not the science) has convinced them they need?" Cancer patients tend not to demand particular drugs, most of which don't get advertised on television. Oncology is a field complex and serious enough that even patients leave it to their doctors. It's the doctors who prescribe the drugs, and they have departments full of people dedicated to making sure they get paid for that drug. (And if they don't, then most practices just eat the loss. But there are a lot of avenues that can be pursued before it comes to that.)
Also bear in mind that British women would also have had world-class cancer care (free at the point of use) before Herceptin even became an issue, whereas an American woman with no coverage would possibly have been facing bankruptcy.
Everyone possibly faces bankruptcy with cancer. It's pricey. But as I've said, there are many avenues. Very few doctors will actually let someone die because they can't afford treatment.
ETA2: I also note with some concern, via Wiki, that "Few reporters have questioned the pricing of this drug but when asked, Genentech refuses to give details to explain the high costs" (
http://www.scoop.co.nz/stories/HL0602/S00144.htm) and that there are serious concerns regarding its effectiveness.
I can only say that Herceptin is in wide use, and given its expense it's
less likely to be prescribed if it didn't actually work. Think about it--the practice has to fight to get paid for it, and probably won't recover all of the cost. Given that, why on earth would we go on prescribing it if there were a better alternative?
I know healthcare is a political and divisive area. But the fact is, the whole industry is much more complicated than people know. I think it's the vocabulary that throws them-- "denial" sounds scary. And the bills don't help, with all those numbers instead of one single figure. There's the charge, the allowable, the insurance payment, the copay, the deductible, the write off...and then most medical bills come aged, which is further complicating matters. Healthcare is an elaborate dance between patient, provider, insurer, and government, with drug companies wafting in and out. It is not simple. And it's so hard to explain every nuance--even people who've been in the business for years don't know it completely.
Which is why I totally distrust news coverage, politicians' ideas, and media punditry on the topic of "healthcare industry", like it's a simple, monolithic, easily-understood entity. Oh god it's not. There can be no simplistic solutions because the system is complex.
I don't think I can possibly explain this any better.
