Longform

COURTING DISASTER

part 1 of 2
Last spring, when Barbara Tepe walked out of her California home, slipped into the car next to her husband and began driving to Colorado, it was not the beginning of a pleasure outing. It was a journey to stay alive.

Six months earlier Tepe had been diagnosed with breast cancer. Although she quickly underwent a radical mastectomy and aggressive chemotherapy, her cancer continued to grow, spreading into her chest. A half-dozen physicians in California recommended she receive a bone marrow transplant to stop the advancing disease.

But when Tepe asked her insurance company to pay for the $150,000 procedure, it refused. In February 1993 she hired a lawyer and filed a request in Denver District Court asking the judge to force Blue Cross/Blue Shield of Colorado to pay. On March 1 the judge ordered the company to write the check. So Tepe, whose Colorado relatives had agreed to help her through her recovery, headed to the University of Colorado medical center in Denver.

The two-month transplant procedure didn't stick. Soon after Tepe returned home to California, her cancer reappeared. By August 1993 she'd had enough of the constant nausea and the aches that wouldn't pass, and she stopped the toxic treatments.

"She decided she just wanted to have some good time before she passed away," says her husband, Lester, an Air Force engineer. Barbara died one year ago last month. She was 52 years old.

So far, Eileen Larsen has been luckier. Diagnosed with ovarian cancer in May 1993, Larsen underwent seven treatments of chemotherapy. During the final one, her doctor told her that her body couldn't handle the toxic drugs again without help. So at the end of last year she flew from her home in Billings, Montana, to CU's medical center, where she was told she was a perfect candidate for a bone marrow transplant.

Like Tepe, Larsen was rejected by Blue Cross/ Blue Shield when she asked the company to cover the treatment. Like Tepe, Larsen, with the assistance of an attorney and a lawsuit, convinced the company to pay. Six months ago she received the transplant. Since then, she says, "I get pretty good news every time I go to the doctor." With her cancer receding, Larsen has returned to her job with the Social Security Administration.

Despite the drastically different conclusions to their stories, Larsen and Tepe still have something in common. Although Blue Cross eventually agreed to pay for each woman's bone marrow transplant, the insurance company has quietly returned through the courts to try to repossess the money.

"Even if I win, I've gone through a certain amount of expense," says Larsen. "But to lose it and then look at that bill would be a frightening thing. Because there's no way I could come up with that money."

A year and a half ago a flurry of lawsuits in Colorado and across the country stoked a debate over whether insurance companies should pay for a promising yet expensive treatment for breast and ovarian cancers. In the suits, women claimed their insurers were denying them a chance at life by refusing to pay the six-figure cost of a procedure called high-dose chemotherapy/autologous bone marrow transplants.

Most of the companies responded that there was no hard and fast evidence proving the treatment was effective, and many labeled it experimental. Insurers often refuse to pay for medical procedures they determine to be of unproven effectiveness.

By this summer it seemed as though the issue was resolved. In the vast majority of the lawsuits, judges had sided with the women and against the insurers. And two months ago, after a day of emotional hearings arranged by Representative Pat Schroeder, the federal government agreed to include the treatment in its standard insurance coverage contract with Blue Cross/Blue Shield (both Larsen and Tepe were covered under the federal plan).

Yet the philosophical fires that kindled the controversy still glow. Several insurance companies, HMOs and self-insured corporations continue to routinely deny coverage for the treatment. Bone marrow transplants for breast and ovarian cancers still rouse high passions and low politics over whether judges have any place forcing insurers and hospitals to pay huge sums of money for a treatment that may or may not work.

The fight also raises uncomfortable questions about how well the medical community evaluates new treatments for deadly --and emotionally charged--diseases. Five years ago, under intense public pressure from AIDS activists, desperate physicians and government regulatory agencies quickly lined up behind a relatively untested drug called AZT as a treatment for HIV-positive patients. Last year, after hundreds of millions of dollars had been spent on AZT, a large European study cast serious doubts on the drug's effectiveness.

Similarly, some insurance representatives say they have been prematurely pressured into paying for bone marrow transplants for breast cancer patients. Why is it, they ask, that such transplants have been used for more than a decade--but that comprehensive clinical trials designed to clearly test their effectiveness are beginning only now?

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Eric Dexheimer
Contact: Eric Dexheimer