The Realities of Health Care Economics Meet Personal Tragedy

I suspect that we'll be hearing more about the tragic case of Nataline Sarkisyan, a 16-year-old girl who died of liver failure following a reportedly successful bone marrow transplant for leukemia. CIGNA, her insurer, denied coverage for a liver transplant until just before life support was withdrawn. They claimed that such surgery was experimental and therefore not a covered benefit.

A few observations here.I suspect that we'll be hearing more about this tragic case in the weeks and months ahead. It's about Nataline Sarkisyan, the 16-year-old girl who died of liver failure following a reportedly successful bone marrow transplant for leukemia. CIGNA, her insurer denied coverage for a liver transplant until just before life support was withdrawn. They claimed that such surgery was experimental and therefore not a covered benefit.

A few observations:

• The LAT article I linked doesn't go into many of the medical details but other articles I've seen suggested that her liver failure was a "known complication" of bone marrow transplants. This leads me to wonder if it arose from hepatic veno-occlusive disease. If this is true (which I have no proof of) then there may have been some justification for attempting a liver transplant. I found several reports in the medical literature of successful liver transplants in this setting. Of course there may have been even more failed operations that went unreported (a death in such a grave setting might not warrant a journal article).
  
  Whether such successes elevate the status of liver transplant for this indication from experimental to accepted therapy is questionable but certainly open for discussion. Of course the grave nature of the patient's condition may have also figured in assessing the futility of the surgery.
  
  
• I was very surprised that the family's physicians claimed a 65% six month survival with the transplant. It seems highly unlikely that such data, if it exists at all, has any degree of reliability. These are rare cases. I think it's interesting that these doctors are now refusing to speak to the press and I wonder how excited they'd be at having to defend those numbers publicly.
  
  
• Insurance companies don't do surgery or practice medicine. Doctors and hospitals do. Why didn't UCLA, the patient's hospital, simply perform the surgery and defer payment from the family or CIGNA until later? If it was such a great idea, why didn't they exhibit the outrage and strength of conviction to go ahead regardless of CIGNA's assessment?
  
  Surely an institution of this size could have absorbed these costs at least until the finances could later be sorted out. This is all the more true given that most such costs are fixed costs that the hospital would incur regardless of whether this particular operation was performed or not.
  
  How is it that the hospital and the doctors' moral standing in this disaster has escaped media attention? My prediction is that eventually, it won't.
  
  
• Predictably, the family has hired an attorney to sue CIGNA for wrongful death. He says that CIGNA "literally and maliciously killed" Sarkosin. I suppose that lawyers can and will say anything they want in order to sell their case to the media and the public but comments like this seem dangerously close to slander.
  
  
• I think that CIGNA's attorneys are going to regret that they approved the transplant at the last moment. To me, this makes their decision appear capricious. I would have been willing to give CIGNA's utilization review process the benefit of the doubt; but by reversing themselves for no other apparent reason than the strident protest occurring outside their offices, they betrayed a sense of arbitrariness.
  
  Believe me, this girl's family will surely capitalize on that.
  
  
• In some circles, this case is already being touted as reason for moving to a universal health care system. This is a curious argument. I looked at some data and did some rudimentary (though not robust enough for publication) calculations that suggest the opposite. Canada appears to do 32% fewer liver transplants than the U.S. on a per capita basis and the U.K. does 42% fewer.
  
  It seems to me that if it's more liver transplants you want, you'd do better to come to the U.S. than a country with socialized medicine.

This case isn't going away anytime soon.