Paul's Heart

Life As A Dad, And A Survivor

“Aetna ‘Screw You'”

I am just going to warn you, right away, I am furious about this post.  I am typing it “raw”, in other words, I am not going to edit the content.  I want to make sure that you get as angry or upset as I am.  Because this should not be happening.

 (photo courtesy of CNN)

This is 15 year old Cara Pressman.  Since the age of 9, she has dealt with seizures (epilepsy).  While I have not personally experienced seizures, I know of a few friends who do, for a long time.  And other than being on medication to control these seizures, that was the only hope my friends had to keep them under control, but not cure.

There is a surgical option, I guess what can be described as a craniotomy, cutting open the skull to expose the brain, to perform the procedures necessary to hopefully provide relief from the seizures.  But a newer option gives even more hope, with less risk, less invasive and faster recovery.  Instead of the craniotomy, just a small hole is drilled into the skull to perform a laser ablation, which destroy the lesions on the brain that cause the seizures.  For those who suffer with these seizures, the process finally offers them quality of life, not the nightmare they face otherwise.

Sounds simple enough.  Patient and her family want the surgery.  The doctors say she is a candidate.  She has health insurance.  There was only one problem.  Her insurance carrier is Aetna, one of the biggest health insurance carriers in the country.  I have written before the statement, “insurance companies are not in business to spend money.”  But with the Epilepsy Foundation approving this method, and the FDA approving this equipment for this surgery, and the ablation surgery itself is cheaper than the older and barbaric method, sure AETNA would approve the ablation.

AETNA denied Cara the procedure.  AETNA declared the ablation procedure experimental.  There were not enough studies done on the procedure.  Forget what the doctors, the Epilepsy Foundation, and the FDA have stated… safer, precise, and cheaper.  AETNA was not convinced this was in the best interest of the patient.

It has been reported that Cara continues to have the seizures, many times a week.

This goes beyond the BIG2 of greediest contributors to unaffordable healthcare, insurance and big Pharm.  An insurance company, who has never seen the patient, overruled what the doctor, who personally knows the patient.  I do not buy for one minute that this was in the best interest of the patient as AETNA claims.  But what does not make sense, is that it does not seem that money – profit – can play a role because the ablation is cheaper.

But this situation brings us right back to the same argument.  Whether you belong to either political party or none, for us to have the best knowledge, skills, and ability to provide the best health care in the world, but to ration it, or make it only affordable to those that can pay for it, or else you suffer or die, situations like this are a travesty.  The Affordable Care Act was not perfect, and what our current government is going to do to health care is far worse.  Healthcare is a right, and should be a right for every US citizen, but it is not.  But if everyone were guaranteed healthcare as we should, situations like Cara’s would not happen.

When I was diagnosed with Hodgkin’s Lymphoma back in 1988, my insurance carrier was not going to cover my treatments if performed in the office.  They needed to be done in the hospital as an outpatient.  There was a hug psychological difference, which I believe would have been crucial for my success.  And it took my employer to improve our insurance coverage.

In 2008, my family doctor, who knows me well enough that I do not complain about ailments and aches and pains, ordered a cardiac test on a then 42 year-old, that should never have been ordered given my age.  But my complaints were serious.  She was not aware that my treatments had caused several late effects, but the most critical was a 90% blockage of the main artery to my heart caused by radiation damage.  But would it not been for her to be allowed to make the decision, regardless if the insurance company felt it was not necessary, I would be dead.

In quality of life, or in saving a life, doctors need to be doctors.  Insurance companies need to butt the Hell out, especially when under normal circumstances decisions are based on greed and profit.  This situation for Cara just makes no sense.

Cara’s response to AETNA’s denial, “SCREW YOU!”  Pretty strong for a 15 year-old.  I would not have been as restrained.  I am hoping that enough people protest the monsters at AETNA for the very ill-informed decision, and they allow Cara to get the better, safer, and less expensive procedure.

Then again, universal health care would give each and every patient access to the best health care that the US has, and without the interference of a greedy insurance company.  Cara is not alone in this position.  There are many others who suffer with these seizures.

***Cara’s story was published on CNN.COM.

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