Thursday, December 27, 2007

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.

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Blogger H G Stern said...


First, Thank You for your kind words.

Second (and FWIW), we were in correspondence with Mr Potter as well, and he also provided us with that internal memo. We hesitated to publish it, however, until we had his permission. Once we'd received that, we also linked to it.

There are no winners here; I happen to agree with you that Cigna should not have approved the procedure. As you've noted, this simply tells people who disagree with a decision that the normal appeals process is unnecessary: just file a lawsuit and hold a press conference, approval will be forthcoming.

I don't see that as a good thing for medicine or health insurance.

December 27, 2007 11:24 AM  
Anonymous Anonymous said...

There is no disputing the fact the procedure would likely not have saved the life of Nataline.

After all leukemia is incurable, and Nataline would have died eventually of leukemia anyways. It's just that know one knows for sure when that time would have been

You did briefly touch on the topic of rationing, which may have been a viable argument in this case, if the US citizens accepted that concept, but that isn't the case here.

The only question in this case is did Cigna renig on it contractual obligation to pay for the transplant, claiming the procedure was not covered because it was experimental and unproven?

That just isn't the case, and is outright deception.

Transplants are performed all the time. Bone marrow transplants, kidney transplants, heart transplants and even liver transplants are performed often, and with many successes. (I'll admit there are failures, but there are failures with any type of procedure.)

IMO, this is just another case of the typical deny and delay tactic practiced by health insurance companies all the time, in order to avoid paying claims and to increase profits, all the time hoping the patient will die before any money is dispensed.

If Cigna really thought they were in the right, they never would have capitulated, or at least never should have. They only did so to avoid further bad publicity, and possible legal action trying to defend and indefensible position.

Unfortunately Cigna didn't change their tune soon enough to save Nataline nor escape the bad publicity, and possible prosecution.

I just hope this case will wake up the American public to just how poor our health care delivery system is in this country, and maybe even put the fear of god into some health insurance executives.

December 27, 2007 3:44 PM  
Blogger The Medicine Man said...


You're confusing things. Liver transplants as procedures are very expensive yet by themselves are not experimental having many successful applications. In fact, the indications for liver transplants expand all the time and people never previously thought to be candidates have subsequently been shown to be.

However, a liver transplant for some patients in which they have no demonstrated benefit would be considered futile or at best experimental. CIGNA determined, at least initially, that such was the case here. There was therefore no contractual agreement to cover this procedure.

Transplants may not be intrinsically experimental but in certain clinical settings, they most assuredly are.


December 27, 2007 5:43 PM  
Anonymous Anonymous said...

a liver transplant for some patients in which they have no demonstrated benefit would be considered futile or at best experimental

I never disputed the fact the procedure may have been futile, but that is not the same as experimental.

I would put that in the realm of rationing, and the last thing I would ever want should the situation get to that point, is to have some profit driven health insurer deciding what is of benefit and what isn't.

In this case, it appears the doctors in charge of the case didn't think the procedure was futile. (Of course that could also bring up another problem with our health care system, that is doctors performing useless or unnecessary procedures, purely to recover the costs of providing free care, or care at substandard reimbursement rates. But I digress, and don't want to get into that discussion right now.)

Still, I would submit to you, if the procedure was beyond the scope of the policy, why did the CEO of Cigna state they went

to not one, but two, independent experts in the field who agreed that the procedure in question, given the patient’s particular circumstances, would not have been an effective or appropriate treatment[?]

And I'll bet that if I tried hard enough, I could two or three doctors, not including the doctors on the case, to state just the opposite.

Still that is not the point here. I'm not disputing whether the procedure would have been worth while or not, I'm only considering whether Cigna renigged on their contractural obligation to provide payment for health care.

I believe they did, partially due to my total disdain for all health insurance companies, as well as the statement referenced above by the CEO of Cigna.

December 27, 2007 6:36 PM  
Anonymous Anonymous said...

First, it is good to see someone step back from the emotion that inevitably accompanies a child's death to look at the medical facts.

Cigna was right to say that a transplant for a child suffering from cancer is "experimental." Usually cancer patients are not put on transplant lists. In this case, probably because of her age, the doctors wanted to give it a try.

The benefit that they cited was that she had a 65% chance of surviving 6 months. In other words, it wasn't going to do this child much good. (I have two children and if one of them was this sick I don't think I would put them through the ordeal of an organ transplant in hopes of gaining another 6 months. But that's just my personal opinion.)
Going back to why this would be seen as an "experimental treatment." While acknowledging that the transplant would, at best, give this girl only six months, the docs at UCLA could reasonably argue that doing the transplant would give them valuable information about how a patient like this would respond to the transplant--information that might help them push the envelope forward in the future.
But haven't read anything that says that the doctgors made that argument. And ultimately, resources are finite. Health care dollars spent on one procedure cannot be spent on another.

From what I have read there was no hope--not even a long shot--that the transplant would save the girl and that she could hope to live a long and healthy life. (Or even live another five years.)

Maggie Mahar

December 27, 2007 7:51 PM  
Anonymous Anonymous said...

Stay on topic Maggie.

We're not discussing whether the procedure would have been worth while here.

I find this all the time with some bloggers etc. When a situation arises that is indefensible, you change the topic.

I think John already established the fact, liver transplants are not experimental. They are performed all the time, and with a lot of success.

Beneficial/worth while and experimental are two different concepts. It's like comparing apples and oranges.

And even then, that discussion is irrelevant. We don't practice rationing in this country. If we can save a life, we save it.

Plus if we were to use that rationale then insurers could justify not paying for any operation, that won't extend a life beyond 6 months, or a year or two years.

And just who is going to decide the cut off point? For profit health insurers? I sure hope not!

So the question remains did Cigna renig on its contractual obligation to provide payment for the transplant?

Yes they did!

Just as a side note, I don't object to the concept of rationing. I believe we do spend far too much money extending the lives of far too many people for very little time, and quality of life benefit.

But until we get to that point, I don't want some profit driven health insurer deciding my fate.

December 28, 2007 7:16 AM  
Anonymous Anonymous said...

maggie, a 6-month survival rate of 65% does not mean that she would have had "at best" 6 months of extended life as a result of the transplant. It simply means that 65% of patients would live to that point and gives no indication of the average lifespan of that 65%. Moreover, UCLA is an outstanding transplant centre and might have better rates than the national average.

December 28, 2007 6:20 PM  

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