
                         Roanoke Times
                 Copyright (c) 1995, Landmark Communications, Inc.

DATE: THURSDAY, February 17, 1994                   TAG: 9402170020
SECTION: NATIONAL/INTERNATIONAL                    PAGE: A8   EDITION: METRO 
SOURCE: Associated Press
DATELINE: BOSTON                                LENGTH: Medium

STUDY CALLS INSURANCE COMPANIES UNFAIR ON CANCER

Insurance companies are often "arbitrary and capricious" when deciding whether to pay for experimental cancer treatments, approving them for some patients and denying them to others equally sick, a study finds.

Health insurance companies generally have the right to refuse payment for questionable treatments. They decide whether to foot the bill on a case-by-case basis.

In the study, doctors examined what this has meant to women with breast cancer who were sent to Duke University for bone marrow transplants. This treatment, though costly and unproven, was the patients' only hope of forestalling or escaping certain death from cancer.

Their review of 533 cases found little consistency in companies' decisions. Overall, they approved the treatment for three-quarters of patients. But those denied care were medically identical to women for whom it was approved.

Not only was the industry as a whole inconsistent, the study found that decisions by individual companies seemed almost random, coming down in favor of the treatment one day and denying it the next.

"They were arbitrary, because they did not follow any medical or scientific decision making," Dr. William Peters said. "They were capricious, because decisions varied from company to company and even within the same company."

Peters, director of Duke's bone marrow transplant program, conducted the study with Dr. Mark Rogers. They published their results in today's New England Journal of Medicine.

An accompanying editorial written by Dr. Donald Light of the University of Medicine and Dentistry of New Jersey was highly critical of the insurance industry.

"The decisions of insurance companies about who is covered, what is covered and how medical services are paid for need to be made on a fair, rational basis subject to public accountability," he wrote.

But an essay by Dr. Stephen Boren of CNA Insurance Co. countered that "insurance companies do not have printing presses to make money to pay claims."

Dr. John Cova of the Health Insurance Association of America added that differences in patients' insurance coverage could have explained why some transplants were approved and others were not.

by CNB