NEWS requires $1,500 in annual individual deductible expenses. “The treatment worked very well for Danni,” remembered Zuckerman. Danni’s colorectal cancer abated but the disease made its way to her lung and liver. That’s when Zuckerman began Folfox, a revised chemotherapy regimen for what would be formally labeled as a “second-line treatment,” a regimen that did not include Avastin. “Following what we knew and the base guidelines at the time, we didn’t include Avastin,” said Zuckerman. But a meeting of the nation’s top oncologists as recent as a month ago was a gamechanger, according to Zuckerman, and new hope was on the horizon, or so he thought.
THE CUTTING-EDGE RESEARCH The annual meeting of the American Society of Clinical Oncologists, held in Chicago in early June, attracted more than 30,000 of America’s physicians and cancer specialists. Zuckerman, an ASCO member, said the conference is traditionally a platform for the latest in cancer research. “A presentation at ASCO revealed that Avastin was now having success in second-line treatment,” he said. “This was huge. Needless to say, I was anxious to share the news with Danni but she had already read about it by the time I returned to Boise.” Zuckerman said a control trial had indicated that adding Avastin to the second line of treatment could prolong Danni’s life. “The median age of prolonged life was 1.4 months,” he said. While five weeks may not seem long to most, Zuckerman said Danni would not have the extra five weeks otherwise. “And who knows where Danni is on the curve? Two months? Six more months? She was a strong, healthy woman before this diagnosis and that’s important,” he said but conceded that he was not talking about adding years to his patient’s life. But Zuckerman and Danni’s hope for another season came to a halt on June 21 when Blue Cross said “no” to Avastin for secondline treatment.
THE ARBITER Following Blue Cross’ denial of Avastin as a second-line treatment, Danni’s appeal letter to the insurance company was filled with grief. “I was shocked but also determined to do everything in my power to fight this disease,” wrote Danni. “Never in my wildest dreams did I think that part of this fight would be with my insurance provider.” Blue Cross officials were reluctant to talk to BW about her plight, but after Danni signed a HIPAA waiver, Karen Early, director of corporate communications, and Josh Jordan, corporate communications specialist, sat down for the better part of two hours to discuss what Early agreed was a “dreadful situation.” About 600,000 Idahoans carry Blue Cross of Idaho insurance cards in their wallet. Blue Cross is, by far, the Gem State’s largest carrier, pulling in $1.6 billion in revenues in 2011. WWW. B OISEWEEKLY.C O M
Ninety-six percent of Idaho’s physicians are approved providers in Blue Cross’ network, including Zuckerman, and 100 percent of Idaho’s hospitals, including St. Luke’s and MSTI, are also in the network. When BW told Zuckerman about Blue Cross’ acceptance for an interview, he had a request. “I would ask them to let me do my job,” Zuckerman told BW. “I’m not making things up. This is clear data. I just want to do my job.” But in response, Early said Blue Cross “had a job, too.” “Our job is to act in a way that facilitates hundreds of thousands of people to be able to afford their medical care,” said Early. “It’s our job to make sure that what we pay for has known therapeutic care.” Early revealed that Danni’s appeal process had been bumped all the way up to Dr. Lance Coleman, Blue Cross’ director of medicine, who denied her appeal. Early said Coleman had determined that the standard of care, which according to Blue Cross didn’t include Avastin for second-line treatment, had not been met. “We’ve paid $350,000 for her care for the last two-and-a-half years. It’s not as though Blue Cross hasn’t provided coverage,” she said. “We don’t pay for experimental or investigational drugs.” But Avastin is neither experimental nor investigational. Blue Cross has approved its usage for hundreds of other Idaho cancer patients in first-line care. In fact, Danni’s dilemma may come down to a life-or-death tug-of-war surrounding the words “or” and “and.” Simply put, Avastin’s prescription label recommends the drug’s usage “for first- or second-line treatment.” “That says ‘or,’ not ‘and,’” said Early. “And Dr. Zuckerman is asking for us to approve Avastin for first ‘and’ second line treatment.” If there is a glimmer of hope for Danni and her physician, it may come in new levels of appeals that Early revealed in BW’s interview. “We will offer Dr. Zuckerman and Danni the chance to sit down and talk with our Dr. Coleman,” said Early. “Additionally, we’ll pay for an independent review, outside of our organization, and we’ll be bound by that decision. And we won’t ask that Danni be bound by it in case she still wants to appeal. If an outside investigation reviews all the data and finds in her favor, we’ll pay everything retroactively.” But as BW was going to press on July 18, Danni still faced another $3,300 out-of-pocket bill during her latest chemotherapy treatment. She has even consulted with an attorney about the possibility of divorcing her husband so as not to burden him and their children with mounting debt when she passes. “This is so much more than Danni, more than St. Luke’s, more than Blue Cross,” said Zuckerman. “There are so many people who can’t or won’t bring this fight. I’m so privileged to take care of her. She’s a remarkable woman.”
BOISEweekly | JULY 18–24, 2012 | 9