Presbyterian rejected two appeals, he took his case to a state review board, where he represented himself because he could not afford a lawyer. Presbyterian showed up with two lawyers, a doctor and a nurse. Dr. Bordenave and a gastroenterologist from Albuquerque testified on Mr. Hendrickson’s behalf.
Mr. Hendrickson and his wife had studied the details of their insurance policy and had also learned — with the help of M. D. Anderson — that in the previous five years, the five surgeons Presbyterian had recommended had performed a total of five Whipple operations.
Ultimately, Mr. Hendrickson won the case, and Presbyterian Health Plan paid the entire bill.
A spokesman for Presbyterian said the case had led the company to allow more patients to be treated at high-volume centers if there was evidence that the results would be better.
Mr. Hendrickson said it was “tough to stand up to attorneys and doctors. I don’t know why I was able to do it. I’m stubborn, I guess. I don’t like to be told what to do. Too many people, I know, they just let it go and they die.”"
Getting effective care for the seriously ill--known in the trade as "medical losses". There probably is an important place in any health care system for effective means of utilization review--that is, are patients receiving appropriate care likely to be helpful to their condition (and not just to the pocketbooks of those proving expensive interventions). It doesn't follow that reviewers should have strong personal financial incentives (amply documented in Michael Moore's SiCKO) to deny care. This is a challenge for any health care system, perhaps not best addressed at the bedside of each individual patient, but through research and medical consensus panels. Achieving universal coverage will not make all such problems go away, but it will give us a better shot at getting the incentives right--and considerably more humane (except for those patients with unlimited resources...)