Wednesday, December 26, 2007

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"
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