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

greygooseuria · Dec 23, 2007

I guess living is something only the rich can afford!

Had this been a celebrity, they would have been able to get the transplant in the blink of an eye.

Music in My Heart · Dec 23, 2007

Insurance co's get a really bad rap for being uncaring and money grubbing..

One fundamental problem is with for-profit insurance companies. Their first-and-foremost responsibility is their fiduciary responsibility to their owners and shareholders. That responsibility requires them, by law, to maximize the return to the owners/shareholders. They "owe" it to their shareholders to minimize their payments by whatever means they can achieve within the law and the terms of their contracts. Of course they do whatever they can to minimize payments by denial of care.

I'm a devout believer in the need for non-profit hospitals and single-payer, non-profit coverage. That won't solve the problem by itself but would make a huge dent.

rph3664 · Dec 23, 2007

I guess living is something only the rich can afford!
Had this been a celebrity, they would have been able to get the transplant in the blink of an eye.

Not necessarily. Like I said before, Erma Bombeck had to wait a long time to get her kidney (and her intervening, unrelated cancer delayed this) and died from the operation itself. Walter Payton didn't get a liver either. Nikki Taylor was briefly considered for a liver transplant when her own liver was nearly torn in two in a car accident, but this was withdrawn when it became apparent that her own liver was regenerating. And she recovered completely; imagine what her life would be like now if she DID have a transplant, assuming she would still be here.

It seems that a huge percentage of celebrity transplants are the result of organ damage from substance abuse, and that's something with which I have a huge ethical issue. The transplant center where I did rotations required that a patient be clean BEFORE they went into organ failure, which I'm very aware is awfully hard to prove.

While I was there, we did a kidney transplant on a woman who had destroyed her kidneys from meth abuse (amphetamine induced hypertension). But she had stopped using long before her kidneys failed, although their function was certainly in decline.

greygooseuria · Dec 23, 2007

rph, I meant in terms of money, not necessarily fame. Sorry for the confusion.

pickledpepperRN · 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

Odetta did sing those lyrics. She is amazing still.

Anita Carter (SIL to Johnny Cash) -"All My Trials" -

Simplepleasures · Dec 23, 2007

Odetta did sing those lyrics. She is amazing still.
Anita Carter (SIL to Johnny Cash) -"All My Trials" -

Im tearing up here, what a beautiful song,very poignant in light of the Nataline story.

jeolsz · Dec 23, 2007

"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.

UM Review RN, ASN, RN · Dec 23, 2007

"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.

pickledpepperRN · Dec 23, 2007

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?

Jolie, BSN · Dec 23, 2007

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.

rph3664 · Dec 23, 2007

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.

vamedic4, EMT-P · Dec 23, 2007

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