17- year-old girl needs liver transplant, CIGNA denies

Jolie, BSN · Dec 22, 2007

I wish I could have been a fly on the wall as this situation was going down. When I worked for a large academic facility prior to becoming a nurse, I saw firsthand how physicians could sometimes be pressed to pursue futile treatments. With the talk about a vegetative state, I just can't help but wonder if that were not the case here.
The information currently available probably raises more questions than answers.

This article is the first I have read that addresses some of these questions:

http://news.yahoo.com/s/ap/20071222/ap_on_re_us/teen_liver_transplant

Nataline was diagnosed with leukemia at 14 and received a bone marrow transplant from her brother the day before Thanksgiving. She later developed a complication that caused her liver to fail. She was in a vegetative state for some time, her mother Hilda said....

In a Dec. 11 letter to Cigna, four doctors had appealed to the insurer to reconsider. They said patients in similar situations who undergo transplants have a six-month survival rate of about 65 percent....

The case raised the question among at least one medical expert over whether a liver transplant is a viable option for a leukemia patient because of the immune-system-suppressing medication such patients must take to prevent organ rejection.

Such medication, while preserving the transplanted liver, could make the cancer worse.

Transplantation is not an option for leukemia patients because the immunosuppressant drugs "tend to increase the risk and growth of any tumors," said Dr. Stuart Knechtle, who heads the liver transplant program at the University of Wisconsin at Madison and was not commenting specifically on Nataline's case.

The procedure "would be futile," he said...

Jolie, BSN · Dec 22, 2007

None of us knows the details of coverage in this family's policy. Perhaps CIGNA legitimately denied coverage for the transplant due to stated limitations of the policy, perhaps not. But anyone who thinks that government-sponsored insurance is without limits is mis-informed.

The following thread highlights Medicare's denial of an effective and much less costly treatment.

https://allnurses.com/forums/f195/medicare-won-t-pay-267229.html

http://abcnews.go.com/print?id=3975993

HM2VikingRN, RN · Dec 22, 2007

The medicare issue will ultimately be reversed because medicare is under the control of the people through the political process. Insurance companies are answerable only to shareholders.

PNHP addresses this issue in their FAQ:

There is a myth that, with national health insurance, the government will be making the medical decisions. But in a publicly-financed, universal health care system medical decisions are left to the patient and doctor, as they should be. This is true even in the countries like the UK and Spain that have socialized medicine.
In a public system the public has a say in how it’s run. Cost containment measures are publicly managed at the state level by an elected and appointed body that represents the people of that state. This body decides on the benefit package, negotiates doctor fees and hospital budgets. It also is responsible for health planning and the distribution of expensive technology.
The benefit package people will receive will not be decided upon by the legislature, but by the appointed body that represents all state residents in consultation with medical experts in all fields of medicine.

http://www.pnhp.org/facts/singlepayer_faq.php#run_healthcare_system

Even the expert who is saying a 65 per cent survival rate was giving her a better than even chance for survival. She should have been given the liver given her relatively young age.

Of the 1,107 patients under age 18 who received liver transplants nationally from Jan. 1, 2004 to June 30, 2006, nearly 92% survived at least one year. But most were not as ill as Nataline
...
Dr. Goran Klintmalm, chief of the Baylor Regional Transplant Institute in Dallas, said the operation that UCLA wanted to perform was a "very high-risk transplant" and "generally speaking, it is on the margins."
But Klintmalm said he would consider performing the same operation on a 17-year-old and believes the UCLA doctors are among the best in the world.
"The UCLA team is not a cowboy team," he said. "It's a team where they have some of the soundest minds in the industry who deliver judgment on appropriateness virtually every day."

http://www.latimes.com/business/la-fi-transplant22dec22,1,3777077.story?coll=la-headlines-business&track=crosspromo

Jolie, BSN · Dec 22, 2007

the medicare issue will ultimately be reversed because medicare is under the control of the people through the political process. insurance companies are answerable only to shareholders and the bottom line.
viking,
you state that the medicare issue will ultimately be reversed. perhaps it will, perhaps not. but it hasn't been reversed yet. as much as you like to point out the failings of the private insurance system, cigna's decision was reversed within a matter of days. that doesn't happen when a government bureaucracy is involved, as evidenced by the fact that medicare hasn't yet reversed its decision, and maybe never will.
even the expert who is saying a 65 per cent survival rate was giving her a better than even chance for survival. she should have been given the liver given her relatively young age.

he was giving her a 65% chance of surviving the next 6 months. that is not long-term survival, nor does it indicate any quality of life. the transplant expert from wisconsin indicated that, "the procedure would be futile." as sad as it is, we need to consider the potential benefit when allocating precious healthcare resources, which are limited, whether we like to admit that or not. no system, private or government, can provide unlimited healthcare funding to everyone in every circumstance. there is rationing in any system. that includes rare organs, as well as money. my heart goes out to this family. but it truly sounds like the transplant simply would have prolonged this precious girl's death, not given her any real hope of life and health. we decry prolonging death in micro-preemies and the frail elderly. it is understandable that it is difficult to accept the same for a young woman, but that does not justify the use of limited resources (organs or money) in a case with no hope of meaningful recovery.

pickledpepperRN · Dec 22, 2007

A transplant surgeon speaks out

...Insurance companies are in the business of delivering profits to their shareholders, and multi-million dollars paydays to their executives. They do this by charging exorbitant premiums, cherry-picking applicants, denying care, and retroactively cancelling legitimate policies....
...If the doctors treating Nataline can tell the family and Cigna in a letter that patients in similar situations have a 65% chance of living six months--then it is not experimental as they know the outcome. A 65% chance of living six months does not preclude a 50% survival at 5 years. Also if consent is not required by the Institutional Review Board (IRB), as part of an approved experiment--it is not experimental. If others have already reported the procedure it is not experimental. When something becomes no longer experimental, is a matter of degree that can only be decided by a clinician and individual patient.
The third predictable insurance industry stall is the 'expert' review. I am certain the insurer submits all transplant requests to physicians with minimal, if any, transplant expertise for review.
I would define an 'expert' as a doctor who did a transplant or took care of a transplant patient this week. Insurers and their "medical experts" who review my denials define ANY has-been, retired, unemployed failure with a medical license as an 'expert' who is paid to deny care.
This is practicing medicine without examining the patient or seeing all the data. In effect, the licensed RN and MD working for the insurer, practice medicine unprofessionally and criminally. They violate codes of ethics and should also be prosecuted and disciplined. I doubt, and so should you, the credentials of the oncologist and liver specialist working for CIGNA.
Nataline was killed weeks ago, once the insurer decided to stall...
http://www.dailykos.com/story/2007/12/22/131010/84/561/425556.

...Transplantation is not an option for leukemia patients because the immunosuppressant drugs "tend to increase the risk and growth of any tumors," said Dr. Stuart Knechtle, who heads the liver transplant program at the University of Wisconsin at Madison and was not commenting specifically on Nataline's case....
http://news.yahoo.com/s/ap/20071222/...ver_transplant

jeolsz · Dec 22, 2007

Hey Angie and Space nurse.. here's a link for you:

http://www.cnn.com/2007/HEALTH/conditions/12/20/cancer.uninsured.ap/index.html

rph3664 · Dec 22, 2007

he was giving her a 65% chance of surviving the next 6 months. that is not long-term survival, nor does it indicate any quality of life. the transplant expert from wisconsin indicated that, "the procedure would be futile." as sad as it is, we need to consider the potential benefit when allocating precious healthcare resources, which are limited, whether we like to admit that or not. no system, private or government, can provide unlimited healthcare funding to everyone in every circumstance. there is rationing in any system. that includes rare organs, as well as money. my heart goes out to this family. but it truly sounds like the transplant simply would have prolonged this precious girl's death, not given her any real hope of life and health. we decry prolonging death in micro-preemies and the frail elderly. it is understandable that it is difficult to accept the same for a young woman, but that does not justify the use of limited resources (organs or money) in a case with no hope of meaningful recovery.

i have never seen any evidence that a liver was even available for transplant for her. if anyone does, please post a link.

ita about the procedure quite likely prolonging her death and the immunosuppression possibly making her cancer worse.

i did clinical rotations in a transplant unit, and one thing that automatically disqualified a patient was cancer unless it was a cancerous organ being replaced. remember when erma bombeck needed a kidney transplant, was taken off the list while being treated for breast cancer, eventually got her transplant, and died of complications from the surgery itself?

some of you may disagree vehemently with me, but from what i have seen, most transplant patients have a very poor quality of life afterwards. they are constantly in and out of the hospital, and can rarely have jobs for a number of reasons - loss of medicaid benefits being only one of them. i have certainly seen many exceptions to this, and those are the long-term survivors.

pickledpepperRN · Dec 22, 2007

Here it is.

This is the most comprhensive article I have been able to find regarding this.
"On December 14, Hilda Sarkisyan was told by the hospital that a healthy liver was available, but because CIGNA had refused authorization, the family would have had to make an immediate down payment of $75,000.to proceed, an amount the family could not afford." MONEY was why the doctors and the hospital did not initiate the transplant.
http://www.emaxhealth.com/124/19349.html

SuesquatchRN, BSN, RN · Dec 22, 2007

Spacenurse, emaxhealth is a forum.

HM2VikingRN, RN · Dec 23, 2007

The political process is working to reverse CMS. Going to the original sources the problem lies in inaccurate reporting to CMS the actual cost of this drug class. When the costs ranges from 44 dollars to 66,000 it almost sounds like CMS split the difference to get to the actual costs. If anything this particular incident speaks to the importance of billing transparency.

CMS maintains that the reimbursement changes were based on hospital cost reports for the last three years. According to Don Thompson, acting deputy director of the Hospital and Ambulatory Police Group for CMS, the claims data submitted by hospitals in the past revealed "widely varying reimbursement rates" for radioimmunotherapies. CMS reports that in 2007 the average Medicare payment was $15,400 for Bexxar, and $21,550 for Zevalin. Based on these numbers, Thompson said CMS is "actually increasing payment [for radioimmunotherapies] in 2008."
...
Moules said he believed the data CMS received from hospitals was skewed, because the claims information CMS received on the acquisition price of Bexxar ranged from a low of $44 to a high of $66,000.
One of the reasons for this wide range of charges may be that manufacturers sometimes offered the drug to hospitals at discounted prices.
"Why would a hospital get a drug for & $27K, and only report the charge as $16K? It may be because those hospitals are only being charged by the manufacturers for $16K, and not $27K," a CMS spokesperson said.
...
In reaction to the new Medicare rules, Sen. Debbie Stabenow, D-Mich., proposed an amendment to stop the ruling, which prevents hospitals from providing radioimmunotherapy treatments to non-Medicare patients if they don't offer the treatment to Medicare patients.

http://abcnews.go.com/print?id=3975993

I don't buy that CIGNA ever really intended to pay for this transplant. By denying her the transplant and then extending the appeal process Cigna essentially guaranteed this patients death.

pickledpepperRN · Dec 23, 2007

I heard her mother say this. I believe her.

If it were untrue who doesn't Cigna correct it?

On Dec. 14, Hilda Sarkisyan was told by the hospital that a healthy liver was available, but because CIGNA had refused authorization, the family would have had to make an immediate down payment of $75,000 to proceed, an amount the family could not afford….
http://www.calnurses.org/media-cente...n.html?print=t

Doctors treating Nataline told the family and Cigna in a letter that patients in similar situations have a 65% chance of living six months if they receive a liver transplant. Doctors had qualified Nataline for a transplant Dec. 6 and a liver became available four days later, the family said. But the transplant was not performed because Cigna had refused to approve and pay for the procedure, they said.
http://www.latimes.com/business/la-fi-transplant22dec22,1,3777077.story?coll=la-headlines-business&track=crosspromo

janettalinda · Dec 23, 2007

"If living were a thing that money could buy, then the rich would live and the poor would die."-sung by Odetta