Recently, we were retained by an academic working at a large Canadian university. She had cancer which had spread to her lymph nodes. This was concerning.
She needed a new biologic drug that was appropriate for her situation.
The academic’s doctors put in a claim to the university because the university had taken on the role of payor for drug plans of the academic group of about 5,000 persons.
The university employed a 3rd party company to adjudicate the drug claim.
The adjudicator declined the claim to pay for the biologic. The cost was not trivial. It was about $15,000 per month for at least 2 years. Total cost about $300,000.
However, the drug would have been funded by the contributions of 5,000 persons.
RCM Health was retained by the academic to advocate for her. She needed the biologic to treat her cancer.
RCM Health retained a world class oncologist. He provided us with an expert opinion that supported the academic taking the biologic.
We submitted this expert opinion plus the supporting literature to the adjudicator. I asked for the adjudicator’s oncologist to review the appeal.
They did not have an oncologist on board. Their pharmacist , to my surprise, declined our appeal for the biologic.
The university had chosen to structure a drug plan that did not pay for any drugs that are used “off label”.
I did not understand this because many cancer drugs are used off label if there is a next generation sequencing lab test done to determine the mutations in the cancer DNA.
The mutations will determine which biologic drug to use. Often a lung cancer drug will be recommended for a breast cancer patient. This is off label but totally consistent with
best practices.
The university had found a way to save money. But they were being callous and somewhat cruel in denying cancer drugs to persons with cancer.
Then I tried to understand this lack of empathy. This cruelty. This unfeeling approach to their academic staff.
I happened to be reading “The Power ERCode” by Katty Kay and Claire Shipman.
They reference psychological research into the relationship between power and empathy.
It is clear from the research that those with power are less empathetic. Less feeling. Less concerned with the academics in this case.
And then they reference German philosopher Nietzsche who said that “power makes us stupid”.
And the design of this drug plan that contributes to the early death of the academic members of the drug plan is , in fact, stupid and cruel.
Maybe they should reconsider their drug plan design and fire the drug adjudicator who is ill equipped to help them to make complex decisions.
My job as an advocate for patients is to give a voice to those who have died because of this type of drug plan design.