The Erisa law and how it effects medicine

Dear Dr. ____________

On Tuesday, I made an appointment to speak with the Executive Director of Susan G. Koman. I was delighted to see that they took the issues I raised seriously. I volunteered in earnest to be a speaker for them and specifically, to read research proposals for the organization. I discussed with them the very serious issue of
pre-certification of drugs and scans for cancer patients.

In 2005, I recall that my insurance company began requiring pre-certification for all CT scans, MRIs, Pet scans, Mugascans - basically most radiological studies that are extremely important to patients with serious diseases such as cancer. These scans are essential to diagnosis and to the re-staging of the disease. They are the lynch-pin of treatment. In cancer treatment they are actually routine. In recent years, the drugs that keep cancer patients alive are now subject to pre-certificaiton. I have watched as your office went from a relatively small, friendly place to a very large, extremely hectic office where everyone is rushing in a frantic manner. You have no time and most people have no time. I have been told repeatedly that the dramatic change I have observed in healthcare is due to the extremely difficult rules that the insurance companies have placed on the physicians and their practices. It is pretty obvious and I still remember spending an entire day in your office trying to get a relatively simple drug pre-certified and the crazy problems that occurred.

The root of this problem is apparently Erisa, a law I knew nothing about until I became a cancer patient and you told me about it. Erisa is a law that was passed in 1972 and in section 514 I believe there is language that protects insurance companies from being sued in state courts. Why is this important, it means the insurance companies do not have to worry too much if they deny someone and they are injured. This is where I wish I had a law degree, but this makes insurance companies extremely powerful and basically able to pass on to physicians pretty much any rules they want to save money. They make the decisions about the scans, and by they it is who ever reviews the answers to a group of questions about the patient. More and more requests are being refused or there is just too big a hassle factor involved. So basically, the insurance companies keep tightening the screws, the oncologists have to spend more and more time just trying to get coverage for patients. There is less and less time for patients. Patients in this very vulnerable, fragile, frail group are the most likely to suffer from this sort of complication in the delivery from medicine. They are overwhelmed and some are too sick to question anything, most have no idea that the reason their dr has no time for him or her is because he or she is constantly dealing with insurance snafus. They are not the types to have time or energy to fight back and if they die, they are a grateful group. I have seen many patients die in my eight and a half years. Many people live with cancer, many are cured, but many still die.

I have discovered the the recently proposed health bills have language protecting the insurance companies in this regard. See page 49 of HR 3200. There is language that apparently protects section 514 of Erisa. I feel that any health bill that is going to be passed should include language that protects people with serious illness. At the very least, physicians should be released from these onerous restrictions that are destroying healthcare for the most vulnerable populations.

Sincerely, Mary