Merritt Davis has spent the last few months of
toddlerhood battling with an insurance company. Or, rather, her mom and dad
have. The 15-month-old blue-eyed toddler from Charlotte, N.C., was born with a
rare form of spina bifida, a birth defect in which her spine and spinal cord
didn’t form properly. One of Merritt’s complications is a common one called
neurogenic bladder: her spinal cord and bladder don’t communicate well, leaving
her unable to completely drain her bladder on her own.
Merritt’s parents, Brian and Jenna Davis, empty
her bladder by inserting a catheter four times per day. Merritt’s urologist,
Dr. Winifred Owumi, explained that this process of intermittent catheterization
is essential to Merritt’s health, or she could end up in the hospital with
urinary tract infections, kidney damage and, ultimately, kidney failure. Kidney
failure is a leading cause of death in patients with spina bifida.
The Davises, who have insurance through an
employer, could manage Merritt’s catheter care until they switched their health
benefits from Blue Cross and Blue Shield of Georgia, an Anthem plan, to perhaps
the only commercial health insurer that doesn’t cover basic urinary catheters:
UnitedHealthcare.
Unlike Medicare, most Medicaid programs and most
commercial insurers, UnitedHealthcare—the nation’s largest insurer—excludes
urinary catheters from coverage for many commercial plans, lumping them in the
same category as other excluded disposable supplies like elastic bandages and
gauze.
Appeals denied
The Davises and the care team at the
Charlotte-based Children’s Urology of the Carolinas have gone through the
tedious back and forth process of appealing UnitedHealthcare’s denial with no
luck. They have little reason to believe UnitedHealthcare will change its
determination. This isn’t Owumi’s first patient to be denied coverage for
catheters by the insurer.
“It’s not elective; it’s not a cosmetic
treatment,” Owumi said of using urinary catheters. “I’ve never heard of that
before in my training: that it’s possible for insurance to refuse to pay for
something that’s essential to your care. It’s not, ‘Oh we don’t cover those in
this situation.’ It’s ‘We just don’t cover that.’ ”
UnitedHealthcare has a reputation among
urologists and medical supply distributors for its long-standing exclusion of
urinary catheters. There are blog posts, tweets and Reddit discussions among
patients dealing with the policy.
A UnitedHealthcare spokeswoman said only that it
covers catheters for Medicare and Medicaid patients, but that coverage for
commercially insured members depends on the plan. While she said
UnitedHealthcare could not comment on specific patients, Modern Healthcare
reviewed multiple denial letters the Davises received from the insurer.
UnitedHealthcare also did not respond to questions for this story as to why it
denies coverage for catheters or whether the exclusion is meant to trim costs.
Stories abound of insurers denying coverage for
an out-of-network emergency room visit, a high-cost drug, or some potentially
life-saving medication deemed too experimental, leaving patients on the hook
for huge bills or without the treatment they desired. But there are fewer
stories detailing situations in which insurers deny coverage for seemingly
small, relatively inexpensive items like urinary catheters, even though such an
exclusion can have big consequences for patients who need them.
Since the 1970s, intermittent catheterization
has been the standard way to manage a person’s inability to empty their
bladder, which can be a side effect of spina bifida, multiple sclerosis, spinal
cord injuries or other conditions. Researchers say more than 300,000 people in
the U.S. use intermittent urinary catheters. Patients instead could use an
indwelling catheter, which remains inside the body, but that might come with
higher risk of infection.
One way or another, people have to drain their
bladders. “Think of a bladder that doesn’t empty as sort of a stagnant
pond,” explained Dr. Brian Stork, a general urologist in Muskegon, Mich. “If you
allow that stagnant pond not to drain, over time you get bacterial growth and
urinary tract infections,” adding that the urine could also reflux into the
kidneys and cause damage.
For a patient who catheterizes several times
daily, the price tag for their treatment could be several thousands of dollars
if they use a new one each time. Manufacturers and many urologists, including
Owumi, tell their patients to use a new catheter each time to avoid introducing
more bacteria into the bladder, especially if, like Merritt, they have already
suffered multiple urinary tract infections. The cost of treating a UTI is far
more than a single catheter, totaling around $200 in an outpatient setting
versus $2,000 in an emergency department, a 2013 study by Henry Ford Health System showed.
Emily Spiteri, a 34-year-old legislative analyst
in Minnesota who has been intermittently catheterizing since first grade
because of her spina bifida, explained that she used to hoard catheters and
reuse them over and over when she was insured by UnitedHealthcare through her
husband’s employer. She is now insured by Minnetonka, Minn.-based Medica, which
covers the bulk of the cost of her intermittent catheters.
“When I didn’t have coverage for my catheters, I
had very bad UTIs,” Spiteri said. “I had to go to the ER. I tried to sterilize
them, but I just could not afford to not reuse them.”
Advocating for change
Spiteri is pushing for the Spina Bifida
Association of America to prioritize expanding insurance coverage of catheters
in its lobbying efforts. The association said the UnitedHealthcare plan for its
employees covers catheters, but would not allow Modern Healthcare to see its
plan documents.
UnitedHealthcare’s catheter exclusion is out of
sync with the rest of the insurance industry. One executive at a major U.S.
catheter supplier said he couldn’t point to another with a similar policy,
though there are other insurers that require very detailed documentation from a
doctor before they will cover a more advanced type of catheter. The
executive, who spoke on background because the company does business with
UnitedHealthcare, said patients who don’t have insurance coverage for catheters
must buy them from online retailers who specialize in cash-pay
transactions.
An Aetna official said the insurer covers
urinary catheters when medically necessary. Cigna and Anthem did not respond to
questions about their catheter coverage.
Steve Gottlieb, president of New York-based
urological supplies company Summit Express Medical Supply, said he had to stop
serving all UnitedHealthcare commercial customers because of its policy
exclusion. Summit Express published an urgent notice on its website in 2014
alerting customers of the exclusion and warning that other companies may follow
suit. Indeed, Gottlieb said he’s noticed other insurers reducing the number of
more advanced catheters they will cover per month.
Covered by VA, Medicare
Government health programs have long covered
catheters. In December 2007, the Veterans Affairs Department sent a letter to
clinicians recommending that “catheters identified as single-use devices should
not be reused in any setting. Patients should be provided with an adequate
number of catheters to use a sterile catheter each catheterization.” The VA
noted the U.S. Food and Drug Administration considers urinary catheters to be
single-use devices, as do catheter manufacturers.
A few months later, Medicare began covering up
to 200 basic urinary catheters per month and one packet of lubricant per
catheterization. Before that, the program covered four catheters per month,
which required patients to clean and reuse them. While UnitedHealthcare
considers catheters to be disposable medical supplies, Medicare considers them
a prosthetic device that replaces a body part that’s not working.
While most payers are on the same page about
catheter coverage, there’s limited research and much debate about whether
patients can safely reuse them, which would lower the cost burden for a patient
whose insurance doesn’t cover catheters.
One influential review of evidence by
researchers at the University of Southampton concluded that there is no
convincing evidence that the rate of urinary tract infections is affected by
whether the patient reuses catheters or uses a new sterile one each time. But
that study, which is often cited in other research, was withdrawn from
publication because of possible errors in data analysis. Still, there are other
studies that conclude the use of a new sterile catheter does not decrease the
frequency of bacteria in patients with neurogenic bladder.
The Centers for Disease Control and
Prevention’s guidelines also state
that the “clean technique,” or the reuse of catheters after washing them, is
acceptable, though it notes that more research is needed to figure out how best
to clean and store intermittent catheters.
On the flip side, a 2014 review, which was funded by a catheter
manufacturer, found that literature favored single-use catheters to reduce
urinary tract infections and urethral trauma. Another 2019 literature review in the Canadian Urological
Association journal similarly found that single-use catheters were considered
to impose a lower risk of infection in most studies reviewed. Other researchers
have noted that in lieu of conclusive evidence, clinicians should go with the
patient’s catheter preference.
Dr. John Wiener, a pediatric urologist at the
Duke University School of Medicine who treats at least two patients who have
been denied coverage for catheters by UnitedHealthcare, said he has patients
who have reused catheters for years and never gotten urinary tract
infections. However, he said there are some patients who are prone to
infection who do better using a new catheter each time.
Whether UnitedHealthcare should cover urinary
catheters is a difficult question that depends on whether you think insurance
should cover everything or just big expenditures, like costly hospitalizations
and surgeries, Wiener said, adding, “But given that all other carriers cover
this and it’s part of routine care, I think United is a little out of line by
no longer covering something that is an important part of a patient’s
care.”
UnitedHealthcare did not respond to a question
about whether it has any plans to eliminate its policy exclusion. Some sources
predicted it would take a lot of loud and angry patients before a change is
made.
Depending on the type, intermittent catheters
cost between $1 and $3. Patients may also need to buy packets of lubrication
separately. So a year’s supply of catheters alone could cost as much as $4,400.
But even patients who reuse catheters need several new ones per month.
The cost will burden the Davises, but they will shoulder it because they have no choice. Other patients and families may not be able to do the same.
The cost will burden the Davises, but they will shoulder it because they have no choice. Other patients and families may not be able to do the same.
“The catheters are only one element of cost to
us,” Brian Davis said. Merritt “has a urologist, a neurosurgeon, she has a MRI
coming up at the end of this month. We make enough money that if we absolutely
had to we could buy our supplies without losing our house. But there must be
other families out there that are in a similar situation who don’t have the
same resources.”
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