Mediclaim insurance challenges and solutions – Doctors supporting patients: A Medic LAWgic initiative

INTRODUCTION:Because patients covered by medical insurance are being denied legitimate claims, doctors are working shoulder to shoulder with them and have garnered significant experience in this matter. We, therefore, decided to a systematic survey under the Medic LAWgic banner and presented the data.METHODS:A short, 8-question multiple-choice survey was conducted online among doctor clinicians. Duplicate replies were removed. The remaining replies were evaluated, interpreted, and the data are being presented here.RESULTS:A total of 377 doctors responded. The majority (208, 55%) had faced problems with medical insurance claims in more than 10% of their patients. Almost half of them (48%) had outright rejection of the claims in more than 10% of their patients. Reduction in claim amounts was faced in more than 10% instances by 262 (70%). The five most common causes for refusal or rejection of claims included failure of patient to disclose pre-existing illness (234, 62%), other insurance policy terms related issues (157, 42%), oral medication (199, 53%), treatment without admission (155, 41%), and treatment with new modes of therapy (152, 40%). As many as 301/377 (80%) doctors had written letters to the insurance companies for supporting their patients’ claim. Such supporting letters from the treating doctors resulted in the claim being accepted or approved in 216 instances (57%).DISCUSSION:Mediclaim denial is a major and growing problem. People who need financial assistance the most are also the most vulnerable to denial. In the USA, such denial rates ranged from 1% to 45% of in-network claims in the year 2017. Unfortunately, <0.5% of patients appealed such claim denial. The insurance regulatory and development authority of India (IRDA) have issued guidelines that all claims need to be settled within 30 days and that insurance companies must fulfill their contractual commitment for genuine claims, even if timely intimation was not possible. Insurance companies are running a business for profit. Hence, even the most expensive plans will have a list of exclusions, in the fine print. Indian patients need to be proactive in following up when claims are rejected or reduced. Doctors are their pillar of support, whose advantage needs to be taken by them. IRDA and consumer courts are also looking after patients’ rights in this matter.CONCLUSION:Patients are increasingly facing challenge of medical insurance companies denying legitimate claims. Doctors help by writing to the insurance companies supporting their patients claim and such letters help in the majority of instances. Patients and their families need to follow up aggressively when their claims are not approved, rejected or reduced. They should also request the help of their doctors when facing such challenges.

Phase II study of cisplatin, etoposide and paclitaxel in locally advanced or metastatic adenocarcinoma of gastric/gastroesophageal junction.

BACKGROUND: Unresectable and metastatic gastric cancers carry a poor and dismal prognosis. Several phase II studies have identified effective anticancer drugs. AIMS: To evaluate safety and efficacy of low-dose cisplatin, etoposide and paclitaxel (CEP) based combination chemotherapy in locally advanced or metastatic adenocarcinoma of gastric/gastroesophageal junction. SETTING AND DESIGN: Prospective single-arm phase II study. MATERIALS AND METHODS: Thirty-three patients were enrolled onto this study, out of which, all but one received cisplatin 15 mg/m 2, etoposide 40 mg/m 2 and paclitaxel 50 mg/m 2, given on day 1 and 4 every week for three weeks in a 28-day cycle. Survival analysis was done using SPSS program. RESULTS: Median age of group was 56 years. Twenty-five were males. Twenty-nine had metastatic/inoperable disease and four patients had recurrent disease. Liver was the commonest metastatic site seen in 15 patients. With a median of 2 cycles per patient, a total of 76 cycles was administered. Grade III or IV toxicity were seen in 11 (35%) patients; diarrhea, 5 patients; vomiting, 3 patients; and neutropenia, 7 patients, 5 of whom also had fever). One patient died of neutropenic fever. Best responses, seen in 32 evaluable patients, were 2 CR (6.1%), 21 PR (63%) and 3 SD (9.2%). Four patients were considered operable after chemotherapy. With median follow-up of 11 months in surviving patients, median OS was 10 months and PFS was 8 months. Median OS was 13 months in responders versus 8 months in nonresponders (P =0.04). Seven patients survived> 12 months. CONCLUSION: Combination of low-dose CEP shows good clinical response and an acceptable toxicity profile in advanced or metastatic adenocarcinoma of gastric/gastroesophageal cancers. Whether addition of 5 FU or capecitabine adds to the benefit should be explored. This may be tested with other standard/conventional protocols in a randomized fashion.

Febrile neutropenia in haematological malignancies.

Fever is the principle sign of infection in neutropenic patient and frequently may be the only evidence of infection. The pattern of fever in neutropenia is non-specific and not pathognomonic of any type of infections or non-infectious process and can be suppressed by the antipyretic effects of drugs such as corticosteroids. Neutropenia, resulting from cytotoxic chemotherapy is the most common risk factor for severe infections in hematological malignancies. The duration of neutropenia also contributes significantly to the risk of serious infections. This risk is significantly greater a lower neutrophil counts, such that 100% patients with ANC <100 cells/microl lasting 3 weeks or more develop documented infections. The prompt initiation of empirical antibiotics in febrile neutropenia has been the most important advance in the management of the immunocompromised host. The initial empirical antibiotic regimen started at presentation of the febrile episode frequently requires modifications especially in high-risk febrile neutropenia. Neutropenic patients who remain febrile despite 4-7 days of broad spectrum antibacterial therapy are at a high risk of invasive fungal infection. Empirical antifungal therapy with Amphotericin B in persistently febrile neutropenic patients and other high risk patients has shown to reduce the risk of invasive fungal infection by 50-80% and the risk of fungal infection related mortality by 23-45% in 1980's. The IDSA has recommended that amphotericin B at 0.5-0.7 mg/kg/day be administered till marrow recovery. This approach is limited however by the adverse effects caused by drug infusion (fever, chills, myalgias, nausea, hypotension and bronchospasm). Lipid formulations which improve the therapeutic ratio of the traditional formulation are available. The safety and efficacy of these formulations is well established. These formulations have comparable efficacy and are less nephrotoxic than conventional amphotericin B.A lipid formulation of amphotericin B is appropriate as initial empirical therapy or as definitive therapy for proven mycosis in high risk patients receiving concomitant nephrotoxic drugs (cyclosporine), those with pre-existing renal impairment and those with protracted neutropenia during which dose limiting toxicity may occur.