A top health oversight official at San Francisco City Hall is now siding with Blue Shield in the high-profile case of an insurance denial that left longtime firefighter Ken Jones without part of his Stage 4 cancer treatment.
“At the heart of the matter is the fact that such services that were denied are not allowed by Medicare,” said Rey Guillen, executive director for the San Francisco Health Service System. “We thoroughly reviewed that information.”
Guillen made the announcement on Thursday during a regularly scheduled meeting of the San Francisco’s Health Service Board, which oversees insurance contracts relating to coverage for more than 58,000 city employees and retirees.
The developments come just one day after the NBC Bay Area Investigative Unit aired an in-depth report on Jones’ insurance denial and the controversy that followed.
Rey Guillen, executive director of the San Francisco Health Service System, determined Blue Shield followed the appropriate protocols in denying a portion of Ken Jones’ cancer treatment.
What did ‘review’ actually entail?
In a seemingly surprising admission during the board meeting, Guillen told commissioners he made those determinations without ever talking to Jones or his oncologist. Guillen also didn’t mention seeking counsel of outside experts to complete the review. In fact, in investigating whether Blue Shield’s denial was justified, Guillen only noted speaking to one entity, Blue Shield.
A retired San Francisco firefighter, who spent nearly two decades willingly putting his life on the line for others, now finds himself fighting for survival while in a battle against his own insurance company. Senior Investigative Reporter Bigad Shaban reports.
I’m outraged…how did they conduct this investigation?
Helen Horvath, talking about what she views as a lackluster review process by the San Francisco Health Board
“I’m outraged,” said Helen Horvath, Jones’ wife, who addressed the board directly during the public comment portion of the meeting. “How did they conduct this investigation? Who did they talk with outside of Blue Shield? Did they talk with any unbiased outside medical reviewer?”
She told commissioners she and her husband had to rely on more than $50,000 in online donations to be able to pay for just one round of the immunotherapy Blue Shield denied. She also told the board her husband recently decided to abandon his Medicare Advantage insurance plan, which was administered by Blue Shield, and instead enrolled in standard Medicare coverage, which is run by the federal government. Upon switching coverage options, Horvath explained Medicare agreed to pay for future rounds of immunotherapy — the very treatment Blue Shield has consistently said did not comply with Medicare guidelines for Jones’ specific stage of Cancer.
“Ken’s full treatment is now being fully covered by straight Medicare,” she explained. “The San Francisco Health Service System shouldn’t allow [Blue Shield] to get away with it for Ken or the other retirees.”
NBC Bay Area reached out to Blue Shield for comment on how Medicare was able to approve immunotherapy for Jones if the treatment, as Blue Shield has maintained, does not comply with Medicare guidelines, but the private insurer did not immediately respond.
Helen Horvath, Ken Jones’ wife, says she was left “outraged” after learning a top official at the city’s oversight health board sided with Blue Shield in its decision to deny medical coverage relating to Jones’ cancer treatment.
Director questioned on whether he contacted Jones’ doctor for review
When a commissioner asked Guillen whether he consulted with Jones’ oncologist as part of the review, Guillen responded, “No,” adding, “this is more of an administrative review of those practices.”
In justifying the denial, Guillen did cite many of the very same arguments that have been previously made by Blue Shield, in which the insurer notes FDA approvals and Medicare guidelines deem the requested immunotherapy as a “first-line” treatment, which means it should be reserved for patients who, unlike Jones, have not previously undergone other forms of cancer medication.
“After reviewing Mr. Jones’ case, we determined that Blue Shield did not withhold appropriate care,” Guillen wrote in a summary to board members.
During his prepared remarks, Guillen also told commissioners when it comes to Jones’ denial, “the same result would have occurred … if any other medical insurance plan was in charge.”
NBC Bay Area asked Guillen to explain how he was able to make that determination, but he did not respond to the request for comment.
Firefighter’s oncologist says Blue Shield is ‘misinterpreting’ medical guidelines
Dr. Matthew Gubens, Jones’ oncologist, disagrees with Blue Shield’s interpretation of medical guidelines. In a recent interview with the NBC Bay Area Investigative Unit, he explained his request for immunotherapy should be considered an extension of Jones’ initial treatment of chemo and immunotherapy, since that regimen was paused ahead of schedule to give Jones the opportunity to undergo experimental drugs aimed at eliminating his cancer.
“I would really see it as a continuation of the first-line [treatment],” he said. “While there are guidelines, they don’t always meet this exact situation of our patient.”
Dr. Matthew Gubens, who is treating Jones’ Stage 4 lung cancer, heads the UC San Francisco Thoracic Medical Oncology Clinic.
Jones’ oncologist helped craft medical guidelines at center of controversy
Gubens says he is quite familiar with the medical guidelines governing cancer treatment since he helped craft them. Gubens sits on an elite panel of physicians with the National Comprehensive Cancer Network, which releases standards of care relating to cancer medications. Those guidelines are widely used by hospitals, physicians, and insurance companies.
“There are gray areas and edge cases among our patients where those guidelines just don’t apply,” he said. “That’s where we hope our training and our experience with hundreds of patients helps us inform how to handle those gray areas and to get some latitude to treat those cases.”
During the Health Service Board meeting, Guillen described his review process as a “partnership” with Blue Shield, but not everyone at the meeting agreed with his conclusions.
San Francisco firefighter Adam Wood, who also serves as vice president of the San Francisco Firefighters Cancer Prevention Foundation, says he is disappointed with what he describes as a lack of due diligence by the San Francisco Health Board to review Blue Shield’s recent insurance denial of cancer treatment for retired firefighter Ken Jones.
“With all due respect, it appears to repeat and endorse Blue Shield’s talking points on this issue without input from the treating physician,” said Adam Wood, vice president of the San Francisco Firefighters Cancer Prevention Foundation, who addressed health officials during the meeting.
“If the board members are interested, there was excellent coverage of that side of the story on NBC Bay Area last night,” he told commissioners. “Please view that story.”
Watch our entire investigative series
Contact The Investigative Unit
submit tips | 1-888-996-TIPS | e-mail Bigad