Officials of Group Health Inc. have changed their minds and agreed to pay $100,000 toward a bone marrow transplant for 14-month-old Jeremy Carle of Elk River, Minn.They denied coverage earlier this year on the ground that bone marrow transplants for neuroblastoma, a rare and usually lethal form of cancer, are experimental.
Michael and Janet Carle, Jeremy's parents, were to take their protest to the health plan's appeals board last night, but Group Health representatives proposed last Friday to pay the first $100,000 of Jeremy's bill at University of Minnesota Hospital even if he receives a bone marrow transplant.
Michael Carle, who had hoped Group Health would cover the entire bill, notified Group Health yesterday that he is accepting its offer. He said university representatives have told him that Medicaid should cover most of the remaining cost. He and his wife have to contribute $6,800 for Jeremy to be eligible for Medicaid coverage, but officials of Group Health and University Hospital have said they will help them come up with the money, Carle said.
George Halvorson, Group Health president, said the reversal doesn't set a precedent on coverage for experimental treatments because the health maintenance organization is merely letting the Carles decide how the money should be spent. He said that Group Health was willing all along to pay $100,000 for the treatment of Jeremy's cancer, but that its policy against paying for "experimental procedures" caused difficulties with the Carles.
Halvorson said the money would have been used for conventional treatment of neuroblastoma, which consists of chemotherapy, radiation and surgical removal of the tumor that doctors believe is very close to one of Jeremy's kidneys. Conventional anticancer treatment for neuroblastoma stops short of destroying all of the patient's bone marrow, leaving open the possibility that some cancer cells remain hidden in it.
The medical treatment proposed for Jeremy would destroy as much of his own bone marrow as possible, leaving him without the strength to fight off infections unless the marrow is replaced. Doctors plan to seed marrow from his sister, Melissa, 7, in the cavities in Jeremy's bones to restore his resistance to disease. The cost of bone marrow transplants at the university ranged from $60,000 to $300,000 last year, depending on the extent of complications. Most were in the $125,000 to $130,000 range. University doctors say Jeremy's chance of surviving with conventional therapy is 10 percent. The bone marrow transplant would boost his chances of survival to 33 to 45 percent.
"This doesn't mean we are going to cover transplants that are still experimental," Halvorson said. He said it does mean that in special cases Group Health may allow parents to decide to select experimental therapy for gravely ill children if two criteria are met: If Group Health doctors agree that the treatment is wise and if Group Health's liability doesn't exceed what it would have to pay for conventional treatment.
Halvorson said the decision, worked out at a meeting of two Group Health officials, two University Hospital officials and the Carles, could set a pattern for all HMOs as a way to handle a vexing problem.
Jeremy, who has been receiving chemotherapy since his illness was diagnosed last December, is scheduled to undergo surgery for removal of the tumor Thursday at Minneapolis Children's Health Center. The bone marrow transplant, if it is done, will be performed later at University Hospital.
Carle is a $25,000-a-year social worker at the Anoka state hospital. He also works part-time evenings as a chemical dependency counselor in Brooklyn Center.