John Edwards Disgraces Himself With Regards to Nataline Sarkisyan

The Wall Street Journal just published an article on the Nataline Sarkisyan case and how it has been exploited by presidential candidate John Edwards. I have never endorsed nor rejected a political candidate in this blog. Today, I'm making an exception. I think that Edwards' actions regarding this case are despicable. It is clear that by giving Sarkisyan's family voice at his political rallies, he has accepted the preposterous notion that CIGNA systematically killed their daughter for profit (which they claim).

It's bad enough when this family's lawyer makes such statements to the press. Malpractice attorneys have a rich and colorful history of trying their cases in the media. In law, this is thought of as mounting a "vigorous" advocacy for one's client. Edwards however wishes to be President of the United States.

In my eye, his actions have firmly established his status as a lightweight. Policy differences aside, I for one would never wish for a president with such a simplified world view.

By the way, I was quoted in this article but my title was mangled a bit. I'm sure that UCLA, my employer was quite surprised to find that I was promoted from assistant to associate professor.

CIGNA Responds in More Detail to the Nataline Sarkisyan Case

Today, I received an email from Wendell Potter of Corporate Communications, CIGNA Corporation. He directed me to an open letter from CIGNA's chief medical officer Jeffrey Kang, MD, MPH that expands on his previous public communication regarding Nataline Sarkisyan.

I think it's rather illuminating and adds credence to the notion that there's more than one side to this story. Of course for those who have made up their minds, this won't matter at all.

I've posted my feelings on this case here and here.

More On Nataline Sarkisyan and CIGNA

More thoughts on the Nataline Sarkisyan/CIGNA case here.I recently blogged about the teenager who died waiting for a liver transplant that never materialized. I ambled through the blogosphere looking for what other people have also written on the subject. While I'm not surprised at the intensity of emotion that has arisen from this case, the utterly inflammatory and often mindless rhetoric being propagated is sobering. It seems that nuance has taken a hike, never to reveal itself.

CIGNA is in a public relations morass from which it can never emerge regardless of what details may later be revealed. A lawsuit against them over this issue will be perceived as all but indefensible and will surely result in a settlement with many zeros. There is no way that such a lawsuit's merits will ever be tested. Unlike CIGNA, this family's attorney has very little to lose from a courtroom battle.

People's minds are made up and will in most cases be impervious to change. The facts of this case are unquestionably grim but can those advocating the public hangings at least imagine the possibility that some technologies may in fact be futile or at best experimental? And if such is the case, can these individuals not recognize the grotesque opportunity costs such expenses represent?

Every dollar spent represents a dollar that could have been spent elsewhere. Everything in medicine and economics is a tradeoff.

For a more reasoned perspective on this case, check out InsureBlog's assessment.

Personally, I think one of the biggest mistakes CIGNA may have made was giving in to the public relations consequences and actually approving the procedure (belatedly). I saw an internal memo posted publicly by a single blog and was hesitant to cite it (being unable to find it elsewhere). Apparently however, it has now been posted by CIGNA itself and it is rather revealing. A quote:

Based on the unique circumstances of this situation, and although it was outside the scope of the plan’s coverage and despite the lack of medical evidence regarding the effectiveness of such treatment, CIGNA decided to make an exception. CIGNA did not reverse the clinical determination that the member’s plan did not cover the transplant.

To me, this is very telling and the implication is that families capable of mobilizing public support will fare better before CIGNA than those not so savy regardless of medical realities. They've all but admitted that the decision to capitulate was based not on science but on emotion.

It's very sad what this says to other CIGNA subscribers who may in the future have their requests for expensive interventions rejected.

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.