Why Couldn't CIGNA Make the Right Decision In the First Place?
The Christmas weekend was full of news stories about a 17 year-old girl who was denied a liver transplant by CIGNA.
The insurer ultimately reversed its decision but the girl died a short time later.
I have no idea if the outcome would have been different had CIGNA made the decision to approve the transplant in the first place.
Health insurance contracts--and government plans like Medicare and Medicaid--rightly contain provisions that can be used to deny payment for unnecessary or inappropriate treatment. If they didn't have these limitations every quack in America would be feeding at the reimbursement trough.
But what these provisions should not do is ever deny a legitimate attempt to save someone's life. The insurer has the burden to act responsibly and, if the family disagrees with the call, provide an independent and fast third-party appeals process for what can be life and death decisions.
This case is a controversial one. A leading liver transplant expert was quoted as saying that a liver transplant is not an option for a leukemia patient like this girl. But her doctors weren't a bunch of money grubbing quacks either--they were part of the very highly respected UCLA Medical Center and lobbied the insurer claiming there was a six-month survival rate of 65% for cases like this if the transplant occurred.
Was this a long-shot and almost certainly doomed to fail? Sounds like it. So, what? If it were your kid you would want even the smallest shot.
CIGNA made matters worse for its public relations situation by reversing its decision at the last minute--what was wrong a week ago suddenly made sense to them as a "unique circumstance." But, the girl died soon after and the family hired famed plaintiff's attorney, Mark Geragos, who wasted no time with headline getting press conferences that played across the cable news channels right up through Christmas eve.
Apparently, as soon as it became clear what a hornet's nest was stirred up, senior management at CIGNA recognized what an indefensible decision this was with the "man on the street" and reversed their policy decision.
Critics of for-profit health care will now be quick to point to a corporate focus on earnings and the almost complete dedication to satisfying shareholders and Wall Street analysts and argue that it has so permeated the company that management has lost the forest for the trees.
Are their critics right that their corporate culture has now evolved to one that has lost track of who the customer is and the ethical imperative that these life and death decisions create for them?
Critics don't have to say CIGNA was wrong here. Senior management at CIGNA said CIGNA was wrong, no matter how they now spin it, when they reversed the company's decision.
The question senior management at CIGNA needs to now be asking is, Why did their organization take on so controversial a potential end of life decision in which they had a financial stake in the first place and then defend it right up until almost the last moment? They apparently used "independent consultants" for advice. But, why didn't they have an on hand, arms length, third-party panel of experts that had no vested interest in making the call on medical appropriateness?
Maybe more importantly, what would you have done?
These are questions everyone in this business might do well to think about. Next time, it could be anyone faced with the same call.
December 25, LA Times: "CIGNA Stands By Decision On Transplant"
7 comments:
Robert--
You're right, the doctors at UCLA are not ambulance chasers.
But they are known for overtreatment. When Dartmouth's researchers looked at individual hospitals they found that Medicare spends twice as much when a patient suffering from chronic disease is treated at UCLA as when a very similar patient is treated at the Mayo Clinic.
And outcomes, doctor satisfaction and patient satisfaction are all much higher at Mayo Clinic.
(And Mayo is not the only more efficient benchmark. UC San Francisco is also much more efficient than UCLA in terms of better outcomes for much lower costs.)
The problem at UCLA is that too many specialists and too many beds drive overtreatment. (Supply drives demand).
But as Dartmouth's Dr. Jack Wennberg said to me: "What can they do-- close down beds and fire specialists? They need to do a certain volume of work in order to continue to finance their loans . . ."
Regarding this particular case: a 65% chance of another six months--this doesn't sound to me like a great benefit, especially because we're probably not talking about 6 months of high quality life.
I have two children, and I wouldn't put one of them through the stress, pain and risks of an organ transplant in hopes of buying six months. I (the parent) might want six months more with my child, but it's to imagine that it's worth it for the patient.
I certainly wouldn't go through a liver transplant to buy another six months for myself.
I don't want to come off as cold hearted, but the only mistake I see here is the last minute reversal. I did some digging on this and Cigna consulted two experts on this and both recommended against financing this procedure. Given that the details will always be clouded by HIPAA, I don't think anyone besides the directly involved parties will know the full stories, and both sides have incentive to advocate their decision. I think people are forgetting that Cigna is an insurance company, not a doctor. Cigna can only decide whether or not they will pay for care, not if the patient receives the care. I have gotten non approved procedures done and had to figure out a way to pay for them. If Cigna violated the contract, nail them, but we can't make contract determinations on emotions
Maggie:
You raise two good points:
1. Does the treatment have an appropriate cost outcome?
2. Is it an ethical thing to do?
My point is that a payer with only a financial stake isn't the right one to make either decision--when it is a life and death matter.
This really gets to why health care isn't your typical business.
I think the big point is being missed. UCLA could of done the procedure then contested the denial later. They dont need Cigma's approval to do the transplant. Also, was a liver just hanging out waiting to be transplanted into this girl. I doubt it. Unfortunatly the Healthcare for all folks have taken the opportinity to use this girl as their poster child for government run healthcare. Why do you think the Government would not also deny the procedure if it were up to them when the evidence didnt support doing it in the first place.
ermurse...
What do you do for a living?
Would you work for a month and then see if somebody might pay you even though they already said they wouldn't?
Doctors are people too, and they have families and mortgages. I sure don't expect them to work for free on the slim hope that the denial would be reversed.
Yours is fantasyland thinking.
Actually, ermurse, there was a liver waiting. It was available six days before CIGNA reversed itself and said it would pay.
And anonymous, the only holdup was that UCLA refused to operate unless it had an upfront $75,000 commitment from the insurer.
Several accounts of the incident have documented both of these facts.
The doctors, as employees of the hospital, would have collected their paychecks regardless. The hospital certainly could have operated, and found somebody, anybody, to pay the bill later, whether through negotiating with CIGNA, or through charitable organizations, foundations, gifts, in-kind donations, whatever. I agree, this is not the way other businesses operate, but that only reinforces Robert's initial point that healthcare is not like every other business.
Ultimately, though, Maggie is right. We don't do end-of-life care very well in this country, and this is yet another example.
I found your blog rather interesting. Cigna Insurance is one of the few insurance companies which does not have too many negative reports. It seems to pay out the reimbursement in time, in full amount. The customer service is also impressively good. www.pissedconsumer.com though displays people’s dissatisfaction with the company. Obviously, there are some gaps in the way the company provides its services.
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