For Diabetic, Wait Is More Agonizing Change In Hmos Means At Least Six More Months In Limbo

Mike Jeffries is dreaming of a hypodermic needle jamming a million pancreatic cells into his liver. Longing for it. Vying for it.

For 18 months, the 52-year-old Spokane man has been eager to become the first person in the United States to get a combination kidney and islet cell transplant. Today, he’s free-falling through a loophole, tethered to a kidney dialysis machine and all of the complications of diabetes.

His medical insurance company is being switched by the Associated General Contractors, a construction trade group that purchases health insurance for its member companies such as the Jeffries family’s B & B Sprinklers.

As of Sept. 1, MSC Premera Blue Cross will quit covering Jeffries’ medical expenses. Regence Blue Shield will take over, said a letter delivered two weeks ago.

P.S.: There’s a six-month waiting period before Regence pays for any transplants.

“My wife and I cried for two or three hours,” Jeffries says of the day the letter came. “It’s like somebody took away the only hope you had of making it.”

Jeffries has been raising a ruckus with the Washington insurance commissioner, attorney general and state legislators. They all tell him that what’s happening to him is legal.

Jeffries’ malady isn’t that he’s trying to get an experimental procedure covered - something insurance companies avoid. The Juvenile Diabetes Foundation and the National Institutes of Health are paying for the islet cell transplant, which takes the insulin-making cells from a healthy pancreas and injects them into a diabetic’s liver, where they again produce insulin and regulate blood sugar.

It’s the routine $60,000 kidney transplant he needs his insurance to fund. MSC/Premera would have covered that part of the procedure, he says.

Regence won’t touch it for at least six months, he adds.

Jeffries’ kidneys, long ailing, totally failed last November. He no longer has the energy to help his three brothers in the family business and is headed for Social Security disability.

Jeffries doesn’t believe he will die if he doesn’t get the transplants for another six months. He will simply live light-headed, suffer severe indigestion with every meal, and remain unable to work in the business his father started 44 years ago.

“The difference is, when you are on dialysis and a diabetic, the deterioration of your health is more dramatic,” Jeffries says, using both hands to reset the University of Washington Huskies hat he says he sports to unsettle Washington State University fans. “You don’t feel good, you are just being kept alive.”

He tires of sitting in the Northpointe Dialysis Center, watching people lose first one leg, then the other. Then their lives.

Neither insurance company will discuss the specifics of Jeffries’ case.

MSC/Premera confirms it covers “medically necessary” kidney transplants.

Regence says it’s likely Jeffries was told his kidney transplant wouldn’t be covered for six months. That’s generally standard policy to discourage people from signing up for health insurance only when they need expensive and dramatic treatment, such as a transplant.

“It’s our job to be good stewards of the health care resources that we receive from our members and employers who purchase coverage,” Regence spokesman Chris Bruzzo says. “That sometimes means we have to make difficult decisions.

“For our members, we’ve got a responsibility to administer our contracts for coverage responsibly and consistently.”

Otherwise, there’s not money left to cover immunizations, hospitalizations, physician care and prescription drugs for other Regence customers.

Insurance problems aside, there is no guarantee Jeffries will become the first kidney-islet cell transplant patient. A half-dozen other patients also are on the University of Washington’s list to get the first transplant, which must come from the same body.

The kidney and the islet cells, harvested from the pancreas, will go to the person on the list with the best blood and body-weight match.

But Jeffries has a mission. He has been a diabetic for 39 years, since he was 13. He’s always known he wouldn’t have a long life. He wants to make it count.

“If I could contribute one thing to society, it would be this. The islet cell transplant,” Jeffries says. “If it works, it will be a cure for type I diabetes.

“I don’t care if I die during the operation, if it will be of some benefit.”