Too Little, Too Late?

This is the inaugural issue of the “Managed Healthcare” blog, but this is not a new effort. I am excited about this new venue and look forward to sharing experiences and garnering insights about what bolsters and what threatens our time-honored profession - the practice of medicine. But more than a blog, the best of these discussions shall be culled to print media. (One caveat at the outset: no contributor’s words shall appear without their expressed permission.)

So let’s begin... Our first discussion has to do with mangled managed care. I promise, however, that this blog is no diatribe. The good ‘guys/gals’ will have their say too. Believe me, it’s no easy task to go from one’s ranting and raving to writing a coherent blog to publishing a journal article, but it has always been worth the effort—both as penitence for having been an HMO medical director and as a pastime when I’m not seeing kids. (I’m a practicing pediatrician in the Hudson Valley of New York).

The premise of the following discussion is that CIGNA refused to pay for a liver transplant, twice, and then only reversed when it was too late; that is, that denial was the proximate cause for the 17-year-old leukemia patient’s demise. The insurer deemed the transplant would have been “experimental,” a contract exclusion, its experts already having determined it would not have been “effective or appropriate.”

Nevertheless, the implication of the article^* was the insurer simply “did not want to bear the expense of her transplant and aftercare.” For that reason, she died an unnecessary and untimely death.

The patient, Nataline Sarkisyan, died December 20, 2007 at the UCLA Medical Center after a recurrence of leukemia that originally was diagnosed at age 14 years. She, however, may have been afflicted by a cascade of untoward events, including liver failure following a bone marrow transplantation, a month earlier. The transplant was suggested because without it, the doctors estimated she had only a 35% chance of living 6 months. The spin on that statistic, however, was that with it, she had a 65% chance to live 6 months--Same difference? Not emotionally!

The article stated that “CIGNA initially refused to fund the procedure, but reversed itself after its decision drew protests and negative publicity. However, "By then the girl was too sick and she died hours later.” (The Managing Managed Care Forum ran in Managed Care Interface from July 2003-April 2008 and online since; the Discussions section of my personal website - ManagingManagedCare.com, is live and has been supporting these efforts since 1991.)

CIGNA’s response

CIGNA pointed out, in rather "artful language, that it had two independent experts (who it didn't identify) who said the recommended transplant 'would not have been an effective or appropriate treatment.'" CIGNA concluded "not just that the treatment was experimental, but that it would not save the girl's life. And yet it agreed to pay for her transplant anyway, and to switch her from the 10 percent of transplant claims it says rejects to the 90 percent it says it grants. (We'll have to take these numbers are face value.)"

Although CIGNA publicly extended their condolences to the family, it didn’t feel responsible for the death, and in a company website statement to CIGNA employees, CIGNA HealthCare President David Cordani and Chief Medical Officer, Jeffrey Kang, MD, MPH, said:

"In reviewing requested transplants, we follow certified processes and evidence-based guidelines published by independent physician and medical organizations, as well as expert scientific journals. As in this case, we often accelerate the process if the specific medical circumstances indicate we should do so. In this case, rather than going through our standard method of appeal, we went directly to not one, but two, independent experts in the field who agreed that the procedure in question, given the patient’s particular circumstances, would not have been an effective or appropriate treatment.

Based on the unique circumstances of this situation, and although it was outside the scope of the plan’s coverage and despite the lack of medical evidence regarding the effectiveness of such treatment, CIGNA decided to make an exception CIGNA did not reverse the clinical determination that the member’s plan did not cover the transplant. In fact, CIGNA went above and beyond the plan and offered to provide payment in the event the procedure should be completed.'"

Below, some physician reader reactions to the aforementioned discussion.

From: Philip C.

Posted: May 2, 2008 8:39 PM

I would be interested in seeing the profit sheet on the CIGNA health products for the last 12 years, because I cannot believe what Gilbert is saying. Could you verify CIGNA's loss of "millions on health insurance"? My general theory is that the Balanced Budget Act of 1996 put insurers into a tailspin, but it only resulted in a two-year blip on total revenues. Thereafter and several mergers later, they have all done pretty well.

From: Gilbert R.

Posted: May 3, 2008 2:09 PM

CIGNA may have committed a bad faith breach of contract, however the physicians and hospital abandoned the patient. Why? Was it that the physicians and hospital decided to make the news in a campaign against managed care? Are they in contract negotiations with CIGNA, and wanted to pull a stunt?

From:

Fredrick H., MD, PhD, Esq

Posted: May 3, 2008 4:29 PM

CIGNA allowed a patient to die over money, and the greed is far greater on CIGNA's side! I would say UCLA had, perhaps, a moral obligation to give free care; CIGNA had a contractual obligation. In fact, you can think of this as they were already paid to accept that risk!

There is no comparison between the degree of guilt of the two actors. If the parents want to sue UCLA too, I wish them well, but they will lose--since Hippocrates, there's been no ethical or legal obligation for a doctor to give free care. Come the revolution when insurance companies are moldering in their graves, and everyone is entitled to free care because they paid for it with their taxes, things may be different.

1. Is the HMO's way of making decisions about coverage fair?
2. Do guidelines such as when and if to do a liver transplant always apply?
3. Is the HMO practicing medicine without a license?
4. Are they "playing G_d?"

Your feedback is appreciated. Please post a comment.

^*The patient, Nataline Sarkisyan, died December 20, 2007 at the UCLA Medical Center after a recurrence of leukemia that originally was diagnosed at age 14 years. She, however, may have been afflicted by a cascade of untoward events, including liver failure following a bone marrow transplantation, a month earlier. The transplant was suggested because without it, the doctors estimated she had only a 35% chance of living 6 months. The spin on that statistic, however, was that with it, she had a 65% chance to live 6 months--Same difference? Not emotionally! The article stated that “CIGNA initially refused to fund the procedure, but reversed itself after its decision drew protests and negative publicity. However, "By then the girl was too sick and she died hours later.”