17- year-old girl needs liver transplant, CIGNA denies - page 6

Life Denied: Nurses, Family of Sick Teen March on Health Insurance Company Thursday - 17- year-old girl needs liver transplant, CIGNA denies... The family and the nurses are urgently appealing to... Read More

  1. by   Simplepleasures
    Quote from spacenurse
    Odetta did sing those lyrics. She is amazing still.

    Anita Carter (SIL to Johnny Cash) -"All My Trials" - http://www.youtube.com/watch?v=ZDEpJ...eature=related
    Im tearing up here, what a beautiful song,very poignant in light of the Nataline story.
  2. by   jeolsz
    "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...."


    OK you guys.. I have a hard time with this, and I don't know why you all don't. There are a lot of steps to be taken with a transplant. You don't say you need a liver and the next day one pops up that is a perfect match. There is a process that take place and it sounds like this process had already been started. However just for argument's sake, lets say they did have a healthy liver ready for transplant for this girl. Doesn't it at all make you sick, that the hospital and physicians don't proceed with the surgery because they don't have the down payment. Who's the villian here?

    I would really like to enlighten and educate you about what I do. I work as a Case Manager for a national health insurance company.. one of the big ones. Everyday I follow members thru their hospitalizations. I look at the stay while it's happening, to see if the member is getting the care he/she requires in the correct amount of time it should take also considering whether he/she is in the right place. I follow criteria such as Millman that gives me a rundown of what I should expect to see as well as using 20 years of hospital, home and hospice nursing experience. If I see something that needs attention I bring it to one of many medical directors.. These physicians are unbelievably educated.. most have more than just a medical degree.. many have MBA's and law degrees.. they in turn, based on medical evidence thru literature and studies make an informed decision as to whether the care is required or can be given in a faster time period or perhaps in a different environment that might be more cost effective and yes.. better for the patient( don't forget the infection rate of hospitals) There are all sorts of case managers that work there.. some with just RN's all the way up to MS and Doctorate.. There are social workers and people who just specialize in quality control( they watching out for your safety!) And yes there are actuaries( bean counters) but all corps have them, including the hospital you work in.. They count bed days and run studies based on DRG's, Diagnosises, etc...Ethically the medical personal are seperated from these departments and decisions are based on medical necessity not cost containment.

    If you thing your premiums are high now, they would be unaffordable with out what we do. One of the things that drove me to what I do know is watching the waste of resources and hospital days that go on at hospitals every day. As a floor I was over burdened by people who really didn't belong there because of uneducated physicians who only knew to place them in an acute facility for a cold. It was frustrating and as a floor nurse, no one cared to listen to what you had to say. But as a case manager, things were very different.. All of the sudden, doctors were required to plead their case to me.. wow what a switch.. and what an education I recieved and continue to recieve everyday. The doctors at the health plan actually want you to learn and love to share their education with you.. I have to say it's the best place I ever worked in terms of job fulfillment and satisfaction.
  3. by   UM Review RN
    Quote from jeolsz
    "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...."


    OK you guys.. I have a hard time with this, and I don't know why you all don't. There are a lot of steps to be taken with a transplant. You don't say you need a liver and the next day one pops up that is a perfect match. There is a process that take place and it sounds like this process had already been started. However just for argument's sake, lets say they did have a healthy liver ready for transplant for this girl. Doesn't it at all make you sick, that the hospital and physicians don't proceed with the surgery because they don't have the down payment. Who's the villian here?

    I would really like to enlighten and educate you about what I do. I work as a Case Manager for a national health insurance company.. one of the big ones. Everyday I follow members thru their hospitalizations. I look at the stay while it's happening, to see if the member is getting the care he/she requires in the correct amount of time it should take also considering whether he/she is in the right place. I follow criteria such as Millman that gives me a rundown of what I should expect to see as well as using 20 years of hospital, home and hospice nursing experience. If I see something that needs attention I bring it to one of many medical directors.. These physicians are unbelievably educated.. most have more than just a medical degree.. many have MBA's and law degrees.. they in turn, based on medical evidence thru literature and studies make an informed decision as to whether the care is required or can be given in a faster time period or perhaps in a different environment that might be more cost effective and yes.. better for the patient( don't forget the infection rate of hospitals) There are all sorts of case managers that work there.. some with just RN's all the way up to MS and Doctorate.. There are social workers and people who just specialize in quality control( they watching out for your safety!) And yes there are actuaries( bean counters) but all corps have them, including the hospital you work in.. They count bed days and run studies based on DRG's, Diagnosises, etc...Ethically the medical personal are seperated from these departments and decisions are based on medical necessity not cost containment.

    If you thing your premiums are high now, they would be unaffordable with out what we do. One of the things that drove me to what I do know is watching the waste of resources and hospital days that go on at hospitals every day. As a floor I was over burdened by people who really didn't belong there because of uneducated physicians who only knew to place them in an acute facility for a cold. It was frustrating and as a floor nurse, no one cared to listen to what you had to say. But as a case manager, things were very different.. All of the sudden, doctors were required to plead their case to me.. wow what a switch.. and what an education I recieved and continue to recieve everyday. The doctors at the health plan actually want you to learn and love to share their education with you.. I have to say it's the best place I ever worked in terms of job fulfillment and satisfaction.

    It's great that you love your job and have doctors bowing at your feet, but that's not a good argument for HMOs and it's really not going to change my mind.

    I've seen too much misery caused by insurance companies making sick people wade through claims processes that would daunt the most intelligent of us.

    Even though as a floor nurse, I'm discouraged with relatively low pay and heavy workloads, I'd rather work there, where I know that if someone is terribly ill, they will get treatment, whether they have insurance or not.

    Insurance companies know their policies are ethically wrong; else why would they have protected themselves from lawsuits? They essentially have a monopoly on health care dollars and they continue unchecked because we cannot sue them when they are wrong.

    More and more, I'm thinking that I should not be buying into this system that will eventually victimize me too.
  4. by   pickledpepperRN
    YES I think the hospital should have done the transplant. And then fight the insurance corporation attorneys.

    * Insurance corporation employ Case Managers following members thru their hospitalizations and looking at the stay while it's happening, and following criteria such as Millman.
    * They employ unbelievably educated physicians most have more than just a medical degree, ( MBA's and law degrees?) who based on medical evidence thru literature and studies make an "informed" decision as to whether the care is required without ever seeing the patient.
    * They employ all sorts of case managers some with just RN's all the way up to MS and Doctorate.
    * They employ social workers and people who just specialize in quality control ( they watching out for your safety!)
    * They employ actuaries who count bed days and run studies based on DRG's etcetera.
    * Doctors are required to plead their case to these employees.
    * They employ lawyers

    HOW DOES THIS DECREASE COST?
  5. by   Jolie
    Quote from spacenurse
    HOW DOES THIS DECREASE COST?

    In a multitude of ways, including preventing 1.) unnecessary admissions to the hospital, 2.) ordering of excessive and unnecessary tests, 3.) use of treatments that are unproven or known to be ineffective, that delay more appropriate care, 4.) prolonged hospitalization caused by delays in obtaining appropriate tests and/or treatments.

    Insurance companies also arrange for second opinions and reviews of care for patients with particularly complex conditions that local physicians may have difficulty addressing without access to tertiary care and sub-specialists, or for patients who are too unstable to withstand trandport.

    Is this a perfect system? Of course not, but no system is perfect.

    In an ideal world, hospitals would not need any non-clinical, bean-counting employees, either, but we know that in reality, they exist. Do we suggest that hospitals do away with their non-clinical staff in order to make healthcare more affordable?

    I am not so naive as to believe that every insurance company decision is made in the best interest of the patient. Nor am I so naive as to believe that every clinical care decision made by a hands-on provider is in the best interests of the patient, either. That's why our system has checks and balances. I personally have seen insurance companies intervene to get more timely and appropriate care for patients on a number of occasions, my family included.
  6. by   rph3664
    Quote from spacenurse
    YES I think the hospital should have done the transplant. And then fight the insurance corporation attorneys.
    Why? So she could suffer for a few more months and die anyway? What person who really did have a chance at recovery AND a relatively normal life wouldn't have had that chance if she received that liver?

    IMO

    I was watching a show about some doctors who do bariatric surgery, and a woman who was obviously a very poor candidate for surgery was turned down by the insurance company, and the nurse blamed the company when in fact the woman failed all the prerequisites needed for surgery - the psychiatrist said it would only replace one set of problems with another, and when she was told to go on a 1,000 calorie diet as practice for how she would have to eat afterwards, she gained an enormous amount of weight instead!

    Remember when bone marrow transplants were touted as being the cure-all for advanced breast cancer, and this salvage therapy was proven to be useless? Truthfully, the insurance companies had a point when they refused to pay for it and that was a main reason why it is rarely done nowadays.

    There may be a lot more to the story that you don't know.
  7. by   vamedic4
    I just have to interject here - many years ago we had CIGNA as our health plan at my facility. I can't say anything about them in other states or areas, but here they absolutely sucked. We'd get bills from collection agencies that should have been paid by Cigna, and we had to literally fight with them any time we got their butts on the phone (eww, that didn't come out right but you get my point I'm sure.)

    rph, I think you're wayyy off here. None of us can predict the future so we can't say for sure if the liver would have been a good match for this patient or not...but if there's a chance of success, why not?? I work on a cardiac stepdown unit - and we have one patient who's had 3 (yes I said THREE) heart transplants. It amazes me that our patient can be authorized for 3 transplants, yet this poor girl in the OP can't get authorized for anything. I bet she'd get it if she were Medicaid, I wouldn't doubt one bit if it were on our dime, but alas....

    I have worked for many years with a liver transplant patient (now a new grad nurse practitioner), she got her liver as an 11 year old, and just turned 30 last month. We have to remember that there are patients who do VERY well after their operations. This patient may well have done that if the liver had been transplanted under the optimum conditions - you know...like when she was stilll "healthy" in the hospital!

    That whole situation is just terribly sad, and incredibly frustrating for the family I'm sure. All the best to them.

    vamedic4
  8. by   rph3664
    VAmedic, are you aware that this young woman had leukemia, some of the treatments had destroyed her liver, and she still had active cancer?

    That's where I was coming from.
  9. by   Mulan
    I don't think 65% is very good odds, and wasn't that a 65% chance of living six months longer?
  10. by   pickledpepperRN
    A transplant surgeon speaks out

    ...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....

    http://www.dailykos.com/story/2007/1.../84/561/425556.
  11. by   pickledpepperRN
    Posted by spacenurse
    * Insurance corporations employ Case Managers following members thru their hospitalizations and looking at the stay while it's happening, and following criteria such as Millman.
    * They employ unbelievably educated physicians most have more than just a medical degree, ( MBA's and law degrees?) who based on medical evidence thru literature and studies make an "informed" decision as to whether the care is required without ever seeing the patient.
    * They employ all sorts of case managers some with just RN's all the way up to MS and Doctorate.
    * They employ social workers and people who just specialize in quality control ( they watching out for your safety!)
    * They employ actuaries who count bed days and run studies based on DRG's etcetera.
    * Doctors are required to plead their case to these employees.
    * They employ lawyers

    HOW DOES THIS DECREASE COST?
    Quote from Jolie
    In a multitude of ways, including preventing 1.) unnecessary admissions to the hospital, 2.) ordering of excessive and unnecessary tests, 3.) use of treatments that are unproven or known to be ineffective, that delay more appropriate care, 4.) prolonged hospitalization caused by delays in obtaining appropriate tests and/or treatments.

    Insurance companies also arrange for second opinions and reviews of care for patients with particularly complex conditions that local physicians may have difficulty addressing without access to tertiary care and sub-specialists, or for patients who are too unstable to withstand trandport.

    Is this a perfect system? Of course not, but no system is perfect.

    In an ideal world, hospitals would not need any non-clinical, bean-counting employees, either, but we know that in reality, they exist. Do we suggest that hospitals do away with their non-clinical staff in order to make healthcare more affordable?

    I am not so naive as to believe that every insurance company decision is made in the best interest of the patient. Nor am I so naive as to believe that every clinical care decision made by a hands-on provider is in the best interests of the patient, either. That's why our system has checks and balances. I personally have seen insurance companies intervene to get more timely and appropriate care for patients on a number of occasions, my family included.
    CIGNA yielded $16.5 billion in revenue in 2006
    http://www.cigna.com/about_us/invest...lstrength.html

    Did the Cigna employee examine the girl before denying her transplant?
    Or discuss it with her physicians?
    Or just use some algarithm?
    Did a Cigna employee even tell the mother, father, brother, and her loved ones in person why?

    Then when it was too late they approved it?
    Where is the evidence of caring in her situation?
    Last edit by pickledpepperRN on Dec 23, '07
  12. by   CocoaGirl
    I am totally at a loss for words here, how can anyone who works in case management at a "big insurance company" state that "...decisions are based on medical necessity and not cost containment." How can anyone sit at a desk, review patient records and make a recommendation to allow or disallow a procedure etc. to be done and have the patients best interest in mind? You have never even seen this patient, you work for the insurance company. I have never once in 20+ years of nursing ever heard of an insurance company recommending care on a patient that was not based on money. Insurance companies are FOR PROFIT and in order to maximize profit for their shareholders they must deny or limit coverage. Insurance companies do not want their members to be ill, this would cost them money. Everything in the insurance industry is profit driven this is why CEO's make millions of dollars in salary.
    No insurance company should have the right to deny treatment for a procedure when they know it will lead to the patients demise. Whether the young girl would have had 6 days, 6 months or 6 years with her family will never be known since CIGNA made that decision. This is just another case of how pathetic our nations health care system has become.
  13. by   Jolie
    Quote from spacenurse
    CIGNA yielded $16.5 billion in revenue in 2006
    http://www.cigna.com/about_us/invest...lstrength.html
    If you examine CIGNA's or any other insurance company's financial statements, you will find that a significant portion of their revenue comes from financial investments that have nothing to do with policyholders' premiums, cost of care, or, as you allege, ill-gotten gains stemming from denial of care. Revenue does not equal profits, BTW.

    This girls' death is tragic, as is the untimely passing of any promising young life. But you will not convince me that a liver transplant in a patient actively fighting leukemia and pneumonia would have been a responsible use of financial or organ resources.

    Had she been otherwise healthy, I would agree that CIGNA's "experimental" limitation was unwarranted. But given that she had 2 active diseases that would have been rendered more virulent by immunosuppressive therapy, I have to agree that the procedure does indeed sound like an experiment.
    Last edit by Jolie on Dec 23, '07

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