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

rph3664 · Dec 23, 2007

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.

Mulan · Dec 23, 2007

I don't think 65% is very good odds, and wasn't that a 65% chance of living six months longer?

pickledpepperRN · Dec 23, 2007

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.

pickledpepperRN · Dec 23, 2007

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?

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/investor_relations/financialstrength.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?

CocoaGirl · Dec 23, 2007

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.

Jolie, BSN · Dec 24, 2007

CIGNA yielded $16.5 billion in revenue in 2006
http://www.cigna.com/about_us/investor_relations/financialstrength.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.

greygooseuria · Dec 24, 2007

To make the assumption that insurance companies aren't in this for profit is very, very misinformed and using clouded judgment, or that someone has a vested interest in insurance companies doing well.

When it comes down to it, I'd rather have socialized health care. My grandfather got a hip replacement in May and has severe rheumatoid arthritis and it didn't cost him a dime and he had to wait all of 2 weeks to get it. I think the US can do it. We pay about equivalent taxes as they do in Canada yet they have so much more.

How about this for an idea? We stop pissing the rest of the world off so much so we have no need for a military!

jeolsz · Dec 24, 2007

Hey Cocoa girl....None of us at the big bad insurance company decide on patient care... the only desicions that are made are whether to PAY for procedures, hospitalizations, etc.. An insurance policy is a product that is sold to a consumer.. It's like buying a house.. It doesn't always include the appliances and window treatments, if you know what I mean.. read your policy.. It will fully explain the rules and what is included in your policy...

And also remember everyone is in it for profit, not just the insurance companies.. remember that no one works for the pure fun of it.. we are all motivated by the need to support ourselves and our families.. and for every CEO you can site, I can also site a rich doctor...

Just remember, insurance companies do not deny treatment, they deny payment for procedures and hospital stays that are not medically necessary.. they base this on studies and medical literature and on medically approved criteria, not on a whim.

CIGNA did not make the decision not to do the transplant.. the medical staff and the hospital made that decision.. If the patient was uninsured, this story would have never made the papers.. but since a big insurance co was involved, its all the sleeze that's fit to print...

Trust me Michael Moore's movie Sicko has more to do with his ego than the current state of our healthcare system.. Unfortunately it's his simpleton logic and slow paced , easy to understand cartoon effects that appeals to the largely unworldly and ignorant masses.. As you can probably tell, I'm not a large fan of a man who makes millions, yet pretends he's one of us!

I don't know, I learned along time ago in college, DON'T BELIEVE EVERYTHING YOU READ! I think it was one of the first things I was taught.. You don't have to agree with me, and believe me, I've thought the same as you a few years ago.. But I have the benefit of seeing the other side.. and believe it or not I didn't see any horns or pitchforks ( although it was alittle hot in the office there.. or could just be the hot flashes I've been getting lately!)

The world is not always so black and white. Just remember there are always 2 sides to every story...

greygooseuria · Dec 24, 2007

jeo, in case you hadn't read my posts, I have also worked for an insurance company and disagree with everything you've said.

I've seen SiCKO and most of it is true. Maybe it is not we who are wrong, but you. You are very, very quick to cast stones and are coming off as very defensive. I'd look within for these reasons.

Simplepleasures · Dec 24, 2007

and also remember everyone is in it for profit, not just the insurance companies.. remember that no one works for the pure fun of it.. we are all motivated by the need to support ourselves and our families.. and for every ceo you can site, i can also site a rich doctor...whatever happened to honor, human decency, no shame in making a profit, but not off the back of your fellow man.
trust mewhy? michael moore's movie sicko has more to do with his ego than the current state of our healthcare system.. unfortunately it's his simpleton logic and slow paced , easy to understand cartoon effects that appeals to the largely unworldly and ignorant masses.. as you can probably tell, i'm not a large fan of a man who makes millions, yet pretends he's one of us!but you seem to like the health insurance corporations, they make billions off of denial of payment schemes.

this is a sad commentary.

HM2VikingRN, RN · Dec 24, 2007

The world is not always so black and white. Just remember there are always 2 sides to every story...

Why work for this?

The reality remains the following:

We spend 2.5 times that of the UK and have worse health outcomes.

Cost related access problems contributed to the death of this girl:

Elvish, BSN, DNP, RN, NP · Dec 24, 2007

Friendly moderator note:

All of us who care about our patients and want the best for them (all of us, right?!) are sickened that a 17yo girl has died from liver cancer. That breaks the heart of the biggest and baddest of all of us.

Please, let us discuss that issue and and the issues surrounding without attacking one another. If you need to, take a deep breath and count to 10 before clicking 'reply', and if you really can't do that without turning the post into an attack, it may be best to just 'walk away' from it.

This has so far been a very interesting, enlightening discussion, and we don't want to close the thread. Please keep things nice. Thanks.