A glorious blend of forces: Presbyterian Health Plan and Whipple

Gordon Hendrickson is a retired administrator for the YMCA and the Spina Bifida Association, and now lives in Albuquerque, New Mexico.

Five years ago, at age 66, routine blood tests found something wrong with his liver. After more tests, he received a diagnosis of pancreatic cancer. His doctors thought they had detected it early enough for surgery to save his life. But he would have to go elsewhere for the rarely-performed surgery, they advised, because doctors in Albuquerque had little experience with the rare, complicated, and risky Whipple procedure he needed.

Studies show that treatment by experienced surgeons and hospitals with much relevant experience greatly increases the odds of survival for patients with pancreatic cancer, and indeed, for many other conditions.

Gordon’s internist, Dr. Kristine Bordenave, found a major cancer center in Houston that could safely perform the Whipple – M.D. Anderson. But his insurer, Presbyterian Health Plan, insisted on selecting from local surgeons who had each performed an average of only a single Whipple.

Since Presbyterian Health Plan had refused to pay for care at M.D. Anderson, Gordon used a new credit card for the deposit, and later got socked with $80,000 of medical bills.

He fought Presbyterian for a year, filing two appeals. He took his case to a state review board, where he had to represent himself because he could not afford a lawyer. He ultimately won the case, forcing Presbyterian to pay the whole bill.

In June, his five-year checkup showed he has been cured of pancreatic cancer. A glorious blend of forces – smart doctoring, luck, and his own wisdom and grit – had come together to save his life.

Advice: You don’t have to accept an insurer’s No as the final answer.

Read the source story in Denise Grady’s July 29 article in the New York Times.