THE BATTLE CONTINUES

(This message is long - Sorry)

There was an article in The New York Times last Sunday, July 29th. The headline was; "Doing Battle With the Insurance Company in a Fight to Stay Alive", written by Denise Grady.

This article was very significant from my point of view, in that the article is about a gentleman from Albuquerque who had pancreatic cancer and wanted to go to MD Anderson in Houston. This sounds like me. The article also is about his insurance carrier, Presbyterian of New Mexico, which is also my insurance carrier. And, the article is about his insurance carrier, Presbyterian of New Mexico, refusing to allow him to go to MD Anderson.

The article states he was lucky as the cancer was found early enough to be cured by surgery. The same applies to me. His local doctors advised him not to have the surgery done in Albuquerque. My endocrinologist basically said the same to me. My doctor said I needed to go to a factory where they do this procedure on a daily basis. He suggested Johns Hopkins or Sloan Kettering. My son, Scott, had researched this subject and asked about MD Anderson, and the doctor was very supportive of that as a choice. Two of my local doctors requested a referral from Presbyterian for MD Anderson.

I will point out, as the article states, this surgery - known as the Whipple procedure, is a very risky, delicate and complicated operation. I have been told the surgery alone could last ten hours or more.

Presbyterian refused to pay for this gentleman's treatment at MD Anderson and insisted it could be done in Albuquerque by their own doctors. In my case, the did give me a referral for s second opinion and surgery. However, just this last week they started denying they ever said anything about surgery. They have continued to change their position throughout the whole process with me. I have had three different approvals for three different processes only to have them tell me later they never approved them.

Presbyterian sent this man a list of five local surgeons. He did research, and with the help of MD Anderson, learned that the five doctors in Albuquerque had performed a combined total of five Whipple procedure surgeries within the past five years. The surgeon I went to in Albuquerque, claimed he did three to four surgeries per year and I think he probably was exaggerating. The surgeon I am working with at MD Anderson does an average of two per week.

I have been told by my surgeon at MD Anderson that my form of cancer is the most serious type. Even though it is a very complex and difficult surgery, without surgery there is little chance of surviving. However, this does not automatically mean a person will have surgery.

MD Anderson must first determine whether or not you are a candidate for the surgery. This takes into consideration your current physical condition and whether or not it is good enough to allow you to survive this grueling surgical procedure. This is the reason MD Anderson insists on various extensive tests to determine your physical condition. They conduct these tests quite differently than other doctors doing the same exam under typical routine conditions.

I do have some current health issues including some issues with my heart, upper respiratory disorder, diabetes, two aneurysms and a few less important issues. I went through a very extensive series of tests with the Cardiologists, the same with the Pulmonary specialist, the most complete and complex CAT Scan I have ever had and extensive X-Rays of everything from the waist up. The biopsy took almost an entire day. In fact I was scheduled to come home the night after the biopsy, I had my airline ticket and had checked out of the hotel that morning. They made me stay in Houston that night because the biopsy was so extensive they felt there could be some chance of internal bleeding and they wanted me right there in case this happened.

The purpose of my last trip to Houston scheduled for last week, and cancelled by Presbyterian two days before I was to leave, was to exactly duplicate the tests I had already gone through to measure any improvement, or lack thereof. Instead Presbyterian forced me to spend a week running all over Albuquerque to have these various tests done by their local doctors. This will obviously make it difficult to know exactly what changes have occurred as most of these local tests were very routine and not nearly as comprehensive as those done by MD Anderson.

When Presbyterian refused to pay for the gentleman in the article to go to MD Anderson, he decided to do it on his own. (How many people would have just given up and accepted an early death as their only alternative?) He was a man of modest means but he had just received an unsolicited credit card in the mail with a $5,000 credit limit. He usually destroyed these unsolicited credit cards, but he kept this one and used it as a down payment to MD Anderson. He did - on his own - go to MD Anderson and is now free from cancer!

He appealed to Presbyterian twice and they refused to pay. He then took his case to the New Mexico Review Board. Because he was a man of modest means, he could not afford an attorney, so he represented himself. Presbyterian showed up with two lawyers, a doctor and a nurse. After hearing the case, the Review Board ordered Presbyterian to pay the entire bill of more than $80,000.

His doctor said; "No patient fighting for their life should have to fight their insurance company too." This is where I am right now.

Early on I met with a team of physicians, nurse practitioners, dietitians and other medical professions and received advice and instruction on what I should do and should not do to improve my chances of survival. This included diet, exercise, activity, rest and other factors which affect your health. One of the most critical factors, which can have a very negative impact of your health according to these experts, is stress.

I have made a concentrated effort to develop and maintain a positive and upbeat attitude about this whole thing. I can joke about it even though I know it is extremely serious. Of course, MD Anderson and everything they do contributes to this being possible. Now I find the one institution that should be doing everything they can to help me have a successful solution to this problem, is the one element of the whole process that is causing a constant and unnecessary stress for me.

Don't worry though - I don't give up easily! And, if I do go down, I promise I will take Presbyterian and a group of their people with me financially if possible. But, in my mind it is not going to get to this. I may have to start kicking some butt right now, and if I do - I am ready for it.

Thanks to all of you for being my friends and my support team through all of this. It is going to work out!

AL