I need some help understanding the CIGNA decision to deny coverage

[rateyes]

to the 17 year old girl who died for lack of receiving a liver transplant.

I understand the outrage at CIGNA and share it. What they did was unconcionable, in my opinion.

Having said that, I also understand that the doctors told the family they would do the surgery, regardless of the insurance decision, if the family would make a down payment of $75,000.00

My question: Are the surgeons not, at least partly, culpable here? Why did they require that kind of down payment? Why did they not simply go ahead and do the transplant to save the young woman's life, and then haggle over payment?

And, why, when the organ is donated in the first place, is such a procedure so costly?

IMO, this is one more argument in favor of the notion that universal health INSURANCE (this family had insurance) does not equal universal health CARE (she had insurance---didn't get the medically necessary care to save her life--which is why I don't like mandated health insurance---we need single-payer health CARE where no one is denied coverage).

Anyone have any answers for me?

[ProSense]

1. Yes, it's the doctors fault

Cigna put greed ahead of life!

Let's spread the blame around so that Cigna is less culpable.

Just as it's the soldiers' fault Bush is a war criminal!

Sorry to be so cynical, but there are many arguments to be made for a better health care system, but trying to shift blame onto caregivers for what an insurance company did is not one I can buy into.

[rateyes]

2. I'm not trying to shift blame...

I'm trying to understand.

[Toots]

23. So you are suggesting that demanding money up front before a life saving operation

is good practice? The doctors are to blame IMO if they went against their oath. Someday you may be in a similar situation and I doubt you would feel the same as you do now..The life saving should come first..or life is not worth anything...

[comradebillyboy]

3. The nsurance company's duty is to maximize

the profits of its share holders, not to provide benefits to its policy holders. Corporations have no other reason for existence than to earn profits for their owners.

[FreakinDJ]

6. So "Profit" before "Life"

and under no uncertain terms should be confused with "Profitting from a Good Life"

[comradebillyboy]

7. Thats what we learned in B-School.

and that how capitalism works and why regulation is needed.

[flashl]

4. Cigna Response

Earlier DU Post

The insurer defends its initial denial of a liver procedure for a teen who died last week.

A Friday funeral was set for the Northridge teenager who died last week after her insurer refused to pay for a liver transplant and then reconsidered. Meanwhile, the girl's health plan stood by its initial decision Monday.

Philadelphia-based Cigna HealthCare has a record of approving coverage for more than 90% of all transplants requested by its members, as well as more than 90% of the liver transplants, company President David Cordani said in a memo addressed to employees and distributed to members of the media.

Nataline Sarkisyan's request was evaluated on an expedited basis using "evidence-based guidelines published by independent physician and medical organizations, as well as expert scientific journals," Cordani said.

[whistle]

5. okay, premeditated greed

[knitter4democracy]

8. The surgery cost way more than that--

And chances were, the hospital wouldn't see any of the rest of the bill, too.

Two surgical teams are involved for transplant. Livers are particularly tricky. There are a lot of blood vessels to clamp off and lots to sew together in the patient. So, it takes very specialized surgeons, nurses, anesthesiologists, and other support staff to do it as quickly as possible without making any mistakes. They can't provide the most expensive service the hospital for free and keep the hospital open. They'd have to cut elsewhere, and that wouldn't be good for anyone.

It's not unusual for hospitals to require some sort of down-payment for expensive surgeries to at least have some of their costs covered. Every pair of gloves, every set of scrubs, every light bulb, every drug, every plastic piece of tubing costs money, and the expertise of the team costs money, too. That's why people have insurance--to cover this sort of expense. Cigna's known to be crappy about paying a single red cent for anything, and really, I'm amazed they paid for any of her cancer treatments and she made it that far. They're one of the worst in the business (Aetna, too).

[rateyes]

10. Thanks. That's the info I was looking for. nt

[Cassandra]

9. Profit uber alles for Cigna

who contribute nothing but obstructionism to the decision.

[OHdem10]

11. I am not defending Cigna, but here is their best argument.

The Young Woman has Leukenia and complications . A Liver Transplant
even if it worked would have only given her a few months to live.
With a transplant she would die anyway seems to be their argument.

[proud2BlibKansan]

13. You know what won me over on this story? The nurses.

When the nurses in CA came forward and joined the battle to ask Cigna to pay for the transplant, I believed in the cause. Seems like nurses would know if the transplant was a viable option for this girl. And you bet I will take their word for it over a fucking insurance company.

[warren pease]

14. "She'd die anyway..."

Hell of a position to take. I'm mortal, therefore I'll die anyway, so why bother with medical intervention at all? Just a huge waste of money keeping me healthy. Unless, of course, I'm performing some useful function that contributes to the continued betterment of the rich and powerful, in which case my health has value to the really important people.

Btw, I'm not calling you out at all, OHdem. Anything but. I realize that's not your position but your take on Cigna's own justifications. And you're absolutely right.

Problem is, that's the inevitable result when life or death decisions are based, even partially, on the bottom line. I suppose there will always be trade-offs between idealism and pragmatism when life-extending decisions are made. But those decisions should be made by medical professionals who only consider the effects of a procedure on the welfare of the patient and not its effects on the profit margins of these parasitic leeches who exist only to siphon off money as it flows around and through this insane scam of a health care system.

Amazing that I detest these filthy profiteering bastards so much that they can infuriate me even on Christmas day. Now back to our regularly scheduled programming.


wp

[pitohui]

16. agreed we're all going to die anyway

who are they to decide that it wasn't worthwhile for this girl to live to be 18?

[midlife_mo_Jo]

19. That adds a different twist. If she wasn't expected to recover from

leukemia, the transplant at that point does become questionable.

I'm for universal payer, but we are not going to get transplants for cancer patients to live for a few months no matter what kind of health care system we have.

[dflprincess]

20. If it's true that she'd only live a few months even with the transplant

then I'd have to agree that she shouldn't have a transplant. Not because of the money, but because of the shortage of organs available for transplant. If a liver had become available and it came down to a patient who didn't have much of chance even with the transplant and one who had the chance to resume a normal (or near normal) life if they got a new liver, I'd have to go with the person with the better chance of survival getting the organ.

[colinmom71]

24. I have to admit that I was shocked that she made it through committee...

It wasn't just the leukemia. She'd had a bone marrow transplant, which involves wiping out a patient's entire immune system, in order to act as a final attempt to get the leukemia into remission. Unfortunately, before it could even be gaged whether the bone marrow had any effect on the cancer, she acquired a severe lung infection that eventually wiped out her kidney and liver function. You can live for a while without a kidney, but you can't at all without a liver.

Well, the last option to even preserve her life after the infection was killed off was to replace her liver. I don't know if there was ever been a patient who has had to have a liver transplant after a bone marrow transplant. It's not just a matter of whether the procedure is experimental, it may well be unprecedented! And even then, there was no evidence whether the leukemia was going to remiss or even if she could survive to address just the basic kidney function issues later on.... All this may make for an engrossing episode of "House, M.D." but in real life, it's a horrible and likely unrecoverable problem to face.

Based solely on her medical issues alone, I'm amazed the transplantation evaluation committee passed her at all for her doctors to then petition for coverage to CIGNA. I'd imagine being so young and relatively healthy despite the leukemia and before the bone marrow transplant complications were largely contributing factors... Even if the girl were to be receiving a directed living donation from a relative, I'd be reluctant to say go forward and put her body through further trauma. Even young bodies can only take so much trauma. I'd like to say to just leave it up to the family, but when does parental desperation need to be addressed as unrealistic (medically)?

[warren pease]

12. It's the nature of the beast...

Making money is what they do; they make more of it by denying claims or refusing to cover certain procedures. They're incapable of acting differently. Might as well expect a wolverine to renounce red meat and live off forest shrubbery instead.

As someone upthread noted, by law the only obligation of a US public, for-profit corporation is maximizing return for its shareholders. That's it. Nothing about good corporate citizenship, the public good, saving lives or anything else that isn't related to jacking up the price per share and maintaining a reasonable P/E ratio (the relationship of price per share to earnings).

We need to dump this murderous system entirely. It's too far gone to tinker around the edges. We simply have to get rid of the profit motive as the driving factor in determining who lives and who dies. We need to decouple the idea of health care from the idea of health insurance.

Health care is what happens when patients and health care professionals interact to, in the best case, successfully diagnose and treat a medical condition or injury.

Health insurance is the protection money you have to pay some parasitic middle man to enable this transaction and keep you out of bankruptcy court.

And keep in mind that for-profit insurers typically waste between 25 and 40 percent of an estimated $2.2 TRILLION gross annual combined income for the industry. And that 25 to 40 percent -- which translates into between $550 billion and $880 billion -- represents money that should have been used to pay legitimate claims but instead goes to paper pushing, shareholder return, executive salaries and bonuses, advertising, marketing and PR campaigns, real estate investments, and investigators who pry into any corner of your life in search of the magic factoid that will allow the company to deny your claim. Great system, eh?

This must end; single-payer is the answer, a well-funded Medicare system is the model, greed is the obstacle. Eliminate profits as a factor in life and death decisions, run the entire system based on serving human needs rather than those of shareholders and CEOs, and the profiteers will go elsewhere for their money.

Invite these vampires into any kind of new health care delivery system and they'll bring with them the seeds of the new system's destruction. This is the fatal flaw in all dem candidates health care proposals -- except for Kucinich, who wants single-payer and wants to eliminate the entire medical insurance industry.

That's a lot of typing for Christmas day.


wp

[KharmaTrain]

15. Managed Risk

It's a calculation the insurance company makes based on the diagnosis and the treatment taken...yep, it's bean counters determining if the company has or is spending too much for the patient's care or that the money spent isn't being spent "wisely". This "risk" includes many transplant procedures that are expensive and that the insurance companies consider a high "risk" based on the overall chances for a long-term recovery/survival and the expense of the treatment. Yep, it's damn cruel and this young lady wasn't the first killed in this manner (and, yes, her premature death is murder AFAIC).

My father was a physician for over 50 years and I helped keep the books in the final years. We had several run-ins with insurance companies that wouldn't honor a claim...kicking it back as either un-necessary or un-authorized. Most times we would protest with a letter and the issue was resolved, but over the years we noticed how the companies were getting tighter and tighter on dealing with appeals and the list of excuses to deny care grew...including fears of malpractice.

The real issue is returning the diagnostic control from the bean counters to the physicians. The insurance companies put their fear of fraud and malpractice at the top of the list. If they sense that a procedure isn't "normal" or "excessive" by their "risk assesment", they deny...also any procedure that they think can result in legal problems...such as a risky transplant that could result in a malpractice suit.

I'm not sold on either plan...Universal or Single Payer, but various aspects of both systems. A for-profit health system is not incompatible with overall health care...but it should be specialized. Every American should be able to walk into any emergency room and get treated. Every physicians should feel free to diagnose and practice as their skills tell them. Yes, there will be abuse, but with a more accessble system and more people involved, the cases will diminish. If a person has the means to pay for extra care or for "cosmetic" procedures, they should be able to arrange such care through their doctor and/or insurer. Insurance companies can and should make a profit through operating within a government-mandated (not controlled) system, but the focus must be on the needs of the patient and the word of the doctor over that of an actuary. If not, more people will die.

[berni_mccoy]

17. Doctors have to pay insurance too and have liability

Many contracts with their insurance and with hospitals probably won't let them do the surgery for free, otherwise, the insurance companies would have a conniption and ask for free surgical care for all their patients. If they do it for free, there are many hurdles to be jumped in order not to be forced to perform free all the time.

[rateyes]

21. That helps answer my question, as well. Thanks. nt

[ticapnews]

18. The estimated costs for a liver transplant

According to the United Network for Organ Sharing (UNOS), estimated charges for liver transplantation are:

Estimated First-Year Charge: $314,600
Estimated Annual Follow-up Charge: $21,900

http://www.cpmc.org/advanced/liver/patients/topics/finance.html

Assuming she only lived another 10 years, CIGNA would have spent over $500K just on the liver transplant. They had already shelled out more money to pay for her treatment up until this point. They looked at her case and decided she was a poor RoI (return on investment) and cut their losses.

I am glad to see the lawyer in the case is going to refer this to the prosecutor for possible criminal charges. This was as sure a case of pre-meditated murder as any you'll see on CSI or Law & Order.

[rateyes]

22. I'm glad to see it, too. nt