Nataline Sarkisyan: Cigna Calculates the Cost of Life (and Death)
Cigna Insurance conducted a cost / benefit analysis and made a risk management decision when it denied Nataline Sarkisyan a liver transplant. In doing so, they established the dollar value of this young woman’s life. At the end of the day, she died at the hands of a certified public accountant rather than a physician.
AP/AR is is business shorthand for “accounts payable / accounts receiveable”. In theory, as long as AR > AP on the corporate ledger, a company is profitable and satisfies the needs of its stakeholders (business partners, customers, vendors, employees, and stockholders). So, most large companies employ teams of individuals who manage corporate risk. Guidelines and protocols are established to enable these teams to make decisions on when it makes economic sense to spend money, approve projects, and invest in research and development.
It’s all about risk management. Keep this in mind as you read further — because you are a risk, not a client — to your healthcare, life, auto, and homeowners insurance providers.
Many Americans wake up today outraged by the case of 17 year old Nataline Sarkisyan. The short story (as I understand it): Ms. Sarkysian had leukemia, and was admitted to a California hospital for a bone marrow transplant. As is possible with such procedures, there were complications, and her kidneys and liver failed. Her brother donated a kidney. She was ready for a liver transplant (a relatively routine procedure in this day and age), but even though hers had failed, her family’s insurance company would not approve the procedure by claiming it was “experimental”. In other words, a bean counter at Cigna made the decision that since they had already shelled out a lot of cash for the bone marrow and kidney transplant, that the cost of a liver transplant and followup care was just too high.
The bean counter at Cigna effectively sentenced Nataline Sarkisyan to death. Even after Cigna reversed course following a public outcry, it was too late. Ms. Sarkisyan passed away the evening that Cigna finally agreed to cover her procedure.
So, what was the value of Nataline’s life to the risk managers at Cigna? I did about two minutes worth of research, and found the following:
According to the United Network for Organ Sharing (UNOS), estimated charges for liver transplantation are:
Estimated First-Year Charge: $314,600
Estimated Annual Follow-up Charge: $21,900
To Cigna, the cost of Nataline’s transplant was like buying a Nintendo Wii. When you buy a Wii, it’s not so much the initial investment in the game machine, but the ongoing followup costs in purchasing games and other hardware add-ons. The risk managers at Cigna who made the decisions in Nataline’s case weren’t so much looking at the cost of the initial transplantation procedure, but the annual cost of followup care and medication.
Nataline was 17 years old. The average lifespan of a woman in America is 79.1 years. So, rounding off, for actuarial purposes she had the potential to live another 62 years. In effect, the costs of the transplant and her first year care ($314,000) were chump change to Cigna. Plus, there were already “sunk costs” - business jargon for payouts already made for her prior procedures. So what was the value of Nataline’s life to Cigna?
The cost of her followup care for the next (projected) 62 years: $1,302,000.
When I first heard the story of Cigna’s denial of coverage for Nataline, two thoughts entered my mind. Why doesn’t the hospital just do the damn procedure, then sort out the financial details afterwards? The second thing: where are the screaming hoards that descended upon Terri Schiavo’s deathbed in Florida back in March of 2005? Wasn’t Nataline’s life just as important? Wasn’t Cigna (in effect) removing her feeding tube by denying coverage?
Perhaps someone should ask Cigna CEO H. Edward Hanaway (annual compensation: $28,820,000).
Democratic Party presidential candidate John Edwards had something to say yesterday about the situation, and perhaps this is why the Washington establishment is so concerned about Edwards’ recent rise in the polls:
“Are you telling me that we’re gonna sit at a table and negotiate with those people?” asked a visibly angered Edwards, challenging the health care companies. “We’re gonna take their power away and we’re not gonna have this kind of problem again.”
We all need to be “visibly angered” and moved to action, particularly when someone like Nataline Sarkisyan would still be alive in Canada, the UK, or even Cuba or Venezuela. The healthcare system in America is broken, and we can no longer accept placing a dollar value on human lives to keep the insurance company bean counters employed.
I am really hoping Edrawds is the (D) candidate. It’s time these insurers where relegated to providing supplementary private insurance on top of universal care for those frightened ow waiting.
also, the median life expectancy after liver transplant is 28 years so it wouldn’t even be as much as you say. and probably she would be dumped from private insurance and put on medicaid at some point. but that’s neither here nor there is it?
i’m pretty sure the ok’ing of the procedure was a pr move, done with the full knowledge that she would die before she was able to get the operation.
Cigna’s act was truly monstrous, and it’s the sort of thing they do to thousands every day. Dead teenagers are just the cost of business in this America. I like Edwards more and more; to elect Obama, Hillary or any Repug will be to perpetuate this system that values profits for the rich over the lives of the poor.
I’m an RN of 30 years. I remember when managed care began its nasty ascent into controlling the health care system, which is now a full-fledged INDUSTRY. The USA is a signatory to the United Nations Universal Declaration of Human Rights, in which it clearly states that health care is a right. The USA has never lived up to its word in signing this historic document and remains the only democracy that does not guarantee health care for its citizens. A simple solution is to deny health care to all members of Congress and the President until American citizens have health care guaranteed. Another solution is for us to stop funding wars and stop meddling in the rest of the world’s affairs, so that we can use those funds to provide real national security - for the American people.
Cigna’s primary responsibility is to it’s shareholders, not it’s policyholders. In the US, health care insurer’s business plan is to transfer wealth from it’s policyholders to it’s shareholders. Paying out claims is bad for business: the best possible way to run US healthcare is to rake in money from policyholders and never pay out a dime of it in claims.
The view of the political leadership is that the US healthcare system is the best in the world, therefore the death of one policyholder must be seen as a sign of how perfect our system is: the corporation’s finances were saved from the cruel depridations of one policyholder.
That Cigna has brazenly gotten away with ordering the death of one of their policyholders is one more proof that the corporate entity has far more rights and freedoms than a human citizen. All this is all the natural outcome of the GOP leadership’s control over the US since Reagan was installed as Acting President in 1980. Those of us that have been paying attention to the results of GOP rule are not surprised at all by the death of Nataline. Disgusted, but not surprised.
Yikes, you should hunt down a clip of what I just saw on Faux news: some blowhard arguing that Cigna should sue the family for slander… The whole panel agreed that the poor insurance company was being victimized by this family and their opportunistic lawyer. Disgraceful.
“…In other words, a bean counter at Cigna made the decision that since they had already shelled out a lot of cash for the bone marrow and kidney transplant, that the cost of a liver transplant and followup care was just too high.”
…so they killed her.
An article in the LA Times today stated “Doctors treating Nataline told the family and Cigna in a letter that patients in similar situations have a 65% chance of living six months if they receive a liver transplant”. I am not a insurance company fan by any means, however, when the author compares this sick girl to the “average american women” in terms of life span, he is either being sloppy, or disingenuous, or both.
John Edwards is right, spot on actually but … there is always a but , right? John Edwards sat still and tight lipped while 500 human beings in North and South Carolina lost the only Lyme Disease doctor in our area. You see, Blue Cross is in on this one. I don’t know how it all started but the Infectious Disease Society of America published some barbaric restrictive treatment guidelines for Lyme Disease. Patients are rarely well or even better at the end of the thirty day treatment regime. But since these guidelines got published, state medical boards have been , should I say, encouraged, to ” go after” doctors treating human beings with Lyme Disease. After the medical boards discipline the docs for ” overtreating” a disease that is nowhere close to well in most cases, Blue Cross Blue Shield moves in and sues the docs for medical and insurance fraud……. voila` the docs are closed and BCBS scores more millions……….
Leonard, ASZ has received 17,375 comments (not including comments on the old site) since the blog was started in 2003.
Yours is about the most bullshit comment I’ve read since I started this thing.
A) You’re taking some right wing, insurance / medical industry spin as fact.
B) What if it was your sister, mother, daughter or wife in the same situation? 65% would look pretty good to you.
And yes, Nataline was an “average American woman” at 17. She had a long life in front of her, liver transplant or not. I was not being sloppy or disingenuous. I was being human - as opposed to you, apparently.
Edwards has it right. Take away health insurance from all members of congress and the administration, and although most senators and representatives can probably afford care, remember Tony Snow had to leave the administration because he couldn’t afford to work in public service. Guess who paid for his cancer treatment. Who pays for Cheney’s heart treatments. Why pays when Shrub drives his bike into a tree.
We can’t even afford insurance because no insurer will cover pre-existing conditions - we just keep our fingers crossed. Show me anyone in their 50’s who doesn’t have a pre-existing condition.
The state of health care in this country SUCKS. I lived in Canada for 35 years and would go back there in an instant, except it would mean giving up a successful business and turning my husband into a Canuck.
Blech….
I do not believe people are looking at the facts. My heart goes out to the family to start with. When the issue of government healthcare comes up i shiver. We as a society need to further research this before signing off on it being better than comercial insurance. Alot of these countrys have increadibly long waiting periods for treatment. Also, this is a very unfortunate case, but how many times does someone stand up to say an insurance company took care of them. I have a child that had open heart surgery. The insurance company at the time asked no questions, i had absolutly no problems, they just sat it up and paid for it. We do have some problems, no system is perfect, however i do not believe we are as bad off as some other countries.
how many times does someone stand up to say an insurance company took care of them. I have a child that had open heart surgery. The insurance company at the time asked no questions, i had absolutly no problems,
Why should they get credit for doing something that you pay for and that they are supposed to do?
The only way to make myself less depressed about this girls murder is knowing that everyone involved big or small in causing this girls death will go to hell. God is less forgiving than some think. If everyone was forgiven, there wouldn’t be a hell.
Every system rations healthcare. Canada rations, the UK rations, France rations and so on. In the UK you wouldn’t get many transplants if you were overweight let alone a smoker or drinker. Do you really think that system would have approved a transplant for someone who’s own doctors said she was unlikely to live out the year? In the UK and all other countries with universal healthcare, they feel there is only a certain amount of money to spend and they ration care to those they think it is most likely to help the longest. I think you are completely wrong about the concern being long term care. She only had a 65% chance to live 6 months let alone 6 or 60 years. I think the insurance company was trying to cut its losses to use your business jargon and tried to weasel out of this on a technicality. They felt she was likely to die anyway and didn’t want to pay any more money for a couple of extra months of life. I don’t like that and I don’t like our healthcare system but you are incredibly wrong to think she would have been better off in the UK or most other developed countries. She had insurance. For the people that have insurance our system is no worse and in many cases better than most developed countries. The problem is the people in our country who do not have insurance.
The parent’s were probably too grieved with their beloved daughter’s situation to effectively fight the insurance company. If this happened to my family I would borrow the money for the transplant and then sue the hell out of the insurance company.
This tells us that every American with health care is at risk.
Nataline neede $314,000.00 the first year and $21,900.00 for annual follow-up care.
The CEO could have paid for the entire cost, up to 62 years, from his earned income.
What is wrong with this picture?
How can CIGNA even think that as an insurance company, that they will be trusted in the future.
When H. Edward Hanaway pulls in $28,820,000.00 and the company refuses to pay out to save this girls life, that is unconscionable.
Jon Edwards has the right to speak out against this. He has fought against companies that refuse to take responsibility for their wrong doings. Many people yell that he is a trial lawyer and somehow that is bad. But without the trial lawyers who will go after big industry, we, the mere citizens have no chance.
So, yes, I think that CIGNA should be charged with at least manslaughter in this innocent victims death. CIGNA did not reverse their decision until there was public outcry.
This is wrong. I do not want to put my life in the hands of people who don’t know me, or don’t care. Their main objective is to make the company money.
She only had a 65% chance to live 6 months let alone 6 or 60 years.
Okay, here’s a little quiz for you:
Jim lived for 60 years, Susan lived for 6 years, and Nick lived for 6 months after their liver transplants.
1) How many of them lived at least six months?
2) What was the percent chance Jim had to live 60 more years?
3) What was the percent chance Susan had to live 6 more years?
4) What was the percent chance Nick had to live 6 more months?
5) Is 65% greater than or less than 0%?
6) If Jim, Susan, or Nick had never gotten sick in the first place how many of them would have had a 100% chance of surviving 6 months?
7) What is the percent chance that you will live until you are 60? 70? 80?
It’s within the realm of possibilities that healthcare elsewhere in the world is not perfect…SO WHAT? You are sitting here trying to convince us that Canada or the UK makes a substandard shoe, completely oblivious to the fact that many here in the good old US of A HAVE NO FEET! Thanks for warning us all about the perils of having healthcare. I for one would find the horrors of Universal healthcare a welcome change to institutionalized neglect.
This is very sad that a CPA determines who should live & who should die. Playing GOD by CIGNA is the ultimate. HMOS (Health Mangling Organization) & Health Insurance are NOTHING BUT PIMPS. They are glorified by the term as managed care providers &all that shit. The US mortality rate will increase as more baby boomers retire & their private insurance companies send them to their graves faster than their normal living time frame. Americans who vote for GOP under the impression of smaller, efficient government, etc will get & have got what they voted for. In fact the cost of administering Medicare is less than 7.5% than private health insurance/HMOs. The ONLY thing that will happen is GOD’s universal law of cause & effect will result in a political uproar & upheaval. Unfortunately the cost will be at least hundreds of thousands of deaths at the cost of the HMO/Health Insurance Companies’ CPAs.
IT is time GOD stormed into the HMO/Health Insurance Companies’ & shut them down for the rest of the life of this planet.
N A G. Arsehole
I am appalled that there are still people nattering on about rationed healthcare and long waits in the countries that enjoy single payer national health care, What the hell do you morons think we have here? That poor girl’s healthcare was rationed to her death. At least she wasn’t forced to wait for treatment. N0. she was told she wsn’t allowed to wait. Those of you still passing on the corporate lies of Big Pharma and the insurance industries need to watch Michael Moore’s “Sicko.” Before you start in on Moore’s alleged “half-truths”, let me inform you that my daughter was studying in the UK a few years ago, and suffered a serious injury. Her treatment was immediate, first rate, and free, so spare us your corporate lies. In any case they are irrelevant. You can’t compare universal health care to the crime that passes for health care in theis country.
So now some of you are thinking (and I use that term in its loosest possible sense), this guy is some leftist boob, trying to foist socialism on us, if not communism. How can that idiot say our wonderful health care system is a crime? Very simple: it is against the law for a mugger to stick a gun in your face and say, “Your money or your life.” We call that criminal behavior. Is it any less criminal for a corporation to do that with a pen or a spreadsheet? Hell, no! The nessage is still txhe same. Your money or your life. NOBODY should have the right or the power to say that to any American. That phrase is inherently criminal. Therefore, health care for profit is inherently criminal. Quod erat demonstrandum.
Edwards is right. You don’t negotiate with those people. They are criminals, and criminal behavior should not be negotiated. It should be banned.
Leonard,
I’m trying to understand your point. You say that you’re not a fan of the insurance companies, as if your point somehow supports their actions, but really, it just shows exactly how ridiculous they were being. You also accuse the author of being disingenuous or sloppy (or both), but he was actually looking at the *worst* case scenario for an insurance company, so that when we look at his analysis, we’re looking at the most they would likely be required to pay.
According to the author’s statistics, a liver transplant operation costs $314,600, including the cost of all necessary follow-up treatments during that first year. Each year after that, the estimated follow-up charge is $21,900. By taking that $21,900 and multiplying it out with the assumption that Nataline would live to the average age, he was showing us what, theoretically, would be roughly the most the insurance company would have to pay - just over a million dollars. As you noted, however, the statistics also show that there is only a 65% chance of her living another 6 months. If that turned out to be the case, then not only would there be no additional follow up cost to the insurance company after the first year, the insurance company wouldn’t even have to pay out the full $314,600 for the first year, since they’d only end up doing 6 months of follow up.
So, while at the worst, the company would have been out $1.5 million, the odds are that they’d actually pay *CONSIDERABLY* less than that - maybe as little as only $200,000 or so. And yet the decided that was still too much to pay and it was better to let the girl die.
Something else to keep in mind, though, is that most insurance companies have a lifetime maximum as to how much they will pay out for each customer. Most companies have a limit of $1 or $2 million - so assuming CIGNA has a similar limitation (and I would imagine they do as almost everyone company does,) even if she’d lived to be 100, their costs would be capped at some point and the Nataline would have had to find some way at that point to pay for whatever treatment might still be needed.
What’s so pathetic, though, is that the CEO of CIGNA could have payed for the the full projection of $1.3 million that the author came up with for a lifetime of treatment for Nataline and still had a take home salary of $27.5 million, instead of the $28.8 he got.
Odd, I wrote the same complaint about the Schiavo values voter crowd before coming here. I guess caring minds do think alike.
I’m so sorry for Nataline and her family. In my opinion, the bean counter should be personally charged with attempted murder. That would certainly make them think twice before sentencing a paying client to death.
If I lived in the US, I’d definitely be voting for Edwards. You don’t negotiate with murderers, you punish them.
I’ll match my Liberal credentials with any one of you, but a few brave souls mentioned some sad facts up above. Any system rations health care, and if we go to any form of government sponsored plan (which I support 100% by the way), there will be rationing there. There has to be. There are “x” amount of dollars to go around and “y” number of patients. And if you don’t just say “everyone get everything they want” then >you have rationing
problem is, cigna sells insurance. it’s not in the health care business.
the sooner people make this distinction the better.
Insurance sellers dont provide healthcare. Period.
Insurance sellers have one way pockets and pay leigons of low level clerks to deny claims that should be paid because they want to keep your money. The aren’t interested in paying it out.
So what if some insureds die while CIGNA stalls their decision? The value of this girl’s life is nothing compared to the multi millions the CEO will get in bonuses for “saving” the company all that money.
The sooner insurance sellers are disentangled from the equation the better.
SINGLE PAYER.
Tax dollars can more than adequately provide sound healthcare for everyone.
Let medical providers do their jobs and let insurance sellers rot in hell where they belong.
…completely disgusted. this makes me ashamed to be American. A 17 year old girl dies because of the RISK. What happened to the idea of just DOING THE RIGHT THING in the first place. Why did Cigna have to be shamed into action? Someone get Michael Moore.
295973432 ] (Score: 1)
In defense of CIGNA, they have to set limits. In this case the young woman had leukemia and multiple organ failure. I cannot believe her family was told that she had a 65% chance of living if she had the liver transplant. Her chances, with everything that was wrong with her, were miniscule. Your saying that she was denied a procedure that would have saved her life shows that you don’t know anything about medicine.
It is likely that the ‘bean counter’ who made the call not to approve of the liver transplant followed a company protocol that says “Don’t approve of procedures that won’t save the patient anyway.” Moreover, I am guessing that the ‘bean counter’ consulted with a physician contracted by CIGNA before saying ‘nay’.
CIGNA could approve of every procedure that’s requested, but they’d be out of business within 6 months.
This poor girl was already too sick to be a good candidate for _any_ transplant.
Cancer, then the aggressive treatments that led to multiple organ failure doomed her, not the fact she didn’t get that last transplant.
And what do you think the prognosis is when a cancer patient is put on a lifetime, heavy-duty course of immuno-suppressants?
I am thankful cooler heads prevailed when my uncle (at age 55) got his heart transplant - many younger, cuter (like Natalie), but sicker patients than he were passed over for that heart.
And what do you think the prognosis is when a cancer patient is put on a lifetime, heavy-duty course of immuno-suppressants?
And what do you think their prognosis is when an insurer denies them coverage? Shouldn’t they have a slim chance rather than none at all? Unfortunately cooler HEARTS always seem to prevail - but hey, that’s just fine to you. Right Ebenezer?
No, because any transplants she received would have gone right into the ground with her.
Remember, the liver wasn’t tossed in the trash - there are always plenty of other candidates for any organ with much better chances of survival than poor Natalie ever had.
As valuable as viable organs are, it isn’t acceptable to waste them on people with as poor a prognosis as she had, regardless of how young or cute.
It is to society’s benefit that organs are allocated to those who have the best chance.
>Shouldn’t they have a slim chance rather than none at all?
Are you human, Bill? I mean that seriously.
Do you have children?
A wife?
A mother and father?
Would you let one of them die because an organ should be allocated to someone else who had a better chance than they in the same circumstance?
I mean, be cold and heartless about it. Be a Cigna CPA in your response. Show us some of that good, olde tyme compassionate conservatism. But remember, it’s your flesh and blood that we’re talking about. What are you gonna do? Stand by and watch them die? Don’t sidetrack your response with any preconceived notions about Nataline’s condition. Straight up - do you let your family member die because someone else has a better statistical chance with the organ?
Certainly, I can understand the parents’ desire to grasp at straws, and I’m sure I’d do the same.
But from a societal standpoint, viable organs are a rare and valuable commodity that should be given to the person with the best chance of survival.
Poor Natalie didn’t come close to having that chance - by the time a viable liver was found, she was already in a “vegatative” state (per her mother), suffering not only from leukemia, but multiple organ failure.
Given her extremely poor prognosis, it would have been more than simply irresponsible to use a viable liver with someone in her condition merely to assuage a grieving parent.
As I said, I’m sure that liver has gone to someone who will be using it for many more years - that would never have been the case with poor Natalie.
ABC NEWS
GOOD MORNING AMERICA
Senior With Fractured Back Battles Insurance Company
Hospital Says Medicare Advantage Plan Would Not Authorize Woman’s Care
By CHRIS CUOMO, JAY SHAYLOR AND JONANN BRADY
NEW YORK, Dec. 21, 2007—
Seventy-seven-year-old Angela Dispenza considers herself fiercely independent. She lives in a modest home with her 83-year-old sister in Queens, N.Y., where she tends her garden and walks to mass each Sunday. She says she loves to spend time in her neighborhood.
The one place she does not like being is in the hospital.
But this summer, the usually active senior citizen found herself on a stretcher in the emergency room at nearby Jamaica Hospital after falling at home.
“I don’t want to be here,” Dispenza said of her hospital stay. “I’ve got a house to take care of [and] bills.”
Dispenza’s family says after the fall, she could not care for herself, much less her home.
After her pain became too much to handle, she was brought to the hospital, where doctors diagnosed Dispenza with a fractured spine.
Multiple physicians confirmed the finding and recommended that Dispenza be admitted to the hospital for pain management and further treatment. But when hospital staff asked Dispenza’s insurance company, Oxford, to authorize her admission to the hospital, the company refused.
Hospital workers say they tried repeatedly to explain to representatives from Oxford why Dispenza needed to be admitted.
Lisa Schneider, the director of social work at Jamaica Hospital, said the insurance company told staff members that “she’s not for admission,” and “that she did not need to be in the hospital.”
Medicare Advantage
Schneider says she was surprised by the difficulty staff members had getting Dispenza’s care approved, because she is a senior citizen.
That’s because most seniors in the United States are enrolled in the government-run health care system called Medicare. As part of the program, seniors are typically treated immediately by hospitals and doctors when they need care.
Medicare does not require patients to receive “pre-authorization” before being treated. The government negotiates the rates at which it will reimburse medical providers for the medical care in advance, and pays providers once the care is provided.
While Dispenza had the option to enroll in the government-run Medicare system when she reached retirement age, several years ago she and her sister opted to enroll in a new version of the program called Medicare Advantage, which is run by private insurance companies.
Originally called Medicare Choice, the program was conceived during the Clinton administration as a way to reduce the escalating cost of Medicare. Supporters argued private insurers could provide medical services to seniors more efficiently than Washington, and could reduce the amount of money the government spent on the program. The program remained small through most of the 1990s.
During the Bush administration’s push to add prescription drug coverage to Medicare during 2002 and 2003, the program renamed Medicare Advantage was overhauled. To entice insurers to create Medicare Advantage plans and enroll seniors, the annual government payments to participating insurers were increased. Almost immediately, analysts say, insurance companies saw a potential financial windfall and began creating new plans and signing up seniors.
As of November 2007, nearly 9 million seniors or 1 in 5 of those enrolled in Medicare have opted for a Medicare Advantage plan.
But as enrollment has swelled and new plans created, critics have become more vocal in their complaints about how Medicare Advantage works.
David P. Rosen, the president and CEO of Jamaica Hospital, said he believes the program is short-changing seniors like Dispenza.
Rosen said this is especially true in areas where the hospital must receive “pre-authorization” from a senior’s Medicare Advantage plan before treating a patient.
“We see frequent evidence of denial of care that would have been a no-brainer under the conventional Medicare program,” Rosen said.
Government audits and other reports appear to back up Rosen’s concerns. ABC News reviewed hundreds of audit reports created by the Centers for Medicare and Medicaid Services. The audits showed Medicare Advantage providers with backlogs of unanswered patient complaints, plans that improperly denied claims, and concerns about marketing practices which do not follow government guidelines.
‘Not Medically Necessary’
In Dispenza’s case, her Medicare Advantage plan which is run by United Healthcare’s subsidiary, Oxford denied a series of pre-authorization requests by Jamaica hospital staff.
Despite Oxford’s refusal to authorize payment for the care, Jamaica Hospital says it had no choice but to treat Dispenza, because of the condition she was in. To send her home, Rosen said, would have been tantamount to malpractice. So doctors admitted Dispenza to an in-patient room after she arrived in the emergency room, and began providing her pain medication.
Staff members say even after Dispenza was admitted, they continued to call the insurer to ask Oxford to authorize her stay. Without the authorization, the hospital says, Oxford will not pay for any of the care it provides, even if doctors believe it is necessary.
In a wide-ranging interview with “Good Morning America’s” Chris Cuomo, staff members who cared for Dispenza said no matter what evidence supporting the need for Dispenza’s care the hospital provided to Oxford, requests for authorization were denied.
ABC News reviewed medical records, voice mail recordings and letters sent by Oxford that support the staff members’ claims.
Schneider said she was especially disheartened by Oxford’s refusal to pay for acute, or in-patient rehabilitation, a type of intensive physical therapy offered in the hospital, even though Dispenza’s doctors said it provided the best chance for her to walk again.
Nicole Barone, a social worker who worked with Dispenza, says the type of rehabilitation the hospital requested did not seem unusual for the injuries Dispenza sustained.
Yet, Barone says the case manager at Oxford, who had never met Dispenza, told her the senior was not a candidate for rehabilitation and would be better off living in long-term care facility than living at home.
“She said that I should go in and speak to the family regarding whether they wanted to privately pay for her to go into a nursing home,” Barone said.
Barone said she was told Oxford would not cover nursing home expenses.
Frustrated by her interactions with the case manager, Barone asked her supervisor, Schneider, for assistance.
“We had basically begged them, give us a week,” Schneider said. “Try her for a week. If she doesn’t work for a week, then what are you gonna do? You’re not gonna pay us, anyway? We’re going to be in the same boat we’re in now.”
But Schneider said the company told hospital staff “no.”
“Absolutely not,” Schneider said.
ABC News obtained a copy of a letter Oxford sent to Dispenza in August 2007. The letter said acute rehabilitation was “not medically necessary” for her.
Good Business?
Critics of the program including Jamaica’s CEO, Rosen say denying care for Medicare Advantage patients is not good medicine. But, Rosen said, it is good business for insurance companies.
“They’re making a lot of money,” Rosen said. “All you need to do is look at their financials.”
Last year, Oxford’s parent company, United Healthcare, made more than $4 billion. Analysts say some of that profit came from the strength of the company’s Medicare Advantage products, which are paid for by the federal government.
In fact, Democrats in Congress have now begun investigating the rates Washington pays to insurance companies. Recent reports by several government agencies including the Congressional Budget Office show Medicare Advantage plans actually cost the government an average of 12 percent more each year to run than traditional Medicare, even though the program was designed to save tax dollars.
‘Stay in My Bed And Die’
Barone said after Oxford refused to authorize Dispenza’s treatment, the hospital was told to send her home. Dispenza was in too much pain to ride in a regular car, Barone said, so she was sent home in the back of an ambulance.
Barone was asked to tell Dispenza about Oxford’s decision. “She said, ‘well, I guess I’m just gonna stay in my bed, then, and die.’”
After a week at home, Dispenza was back in the emergency room after a therapist visiting her discovered she had developed bed sores. Jamaica Hospital says it admitted Dispenza again without Oxford’s pre-authorization.
In an interview with Chris Cuomo, Dispenza said she was frustrated by the repeated denials from Oxford.
“How dare you do these things to me!” Dispenza told Cuomo when asked what she would say to Oxford. “I was paying every year. Every year. I never failed to pay. That’s why they took me in.”
Dispenza told Cuomo she just wanted to leave the hospital walking.
ABC News asked Oxford and its parent company United Healthcare to respond to Dispenza’s situation on camera. The company refused and directed ABC News to the insurance industry’s trade group, America’s Health Insurance Plans.
In an interview with Cuomo, the group’s spokesperson, Susan Pisano, said seniors who are enrolled in Medicare Advantage, receive better care than those enrolled in traditional Medicare.
“One thing you get if you join the Medicare Advantage plan is better benefits, get broader benefits, you get lower out-of-pocket costs,” Pisano said.
While seniors may get broader benefits, however, the program does have a trade-off: Medicare Advantage plans decide what care seniors get.
Pisano told Cuomo that insurance companies’ decisions about whether or not someone is admitted to the hospital is “not just a question of money.”
“People should be admitted to a hospital when they need to be admitted to a hospital,” Pisano said. “But if they shouldn’t be there, then a hospital brings risks with it that shouldn’t you shouldn’t have to confront unnecessarily.”
“Do you think that happens a lot that somebody goes to the hospital and doesn’t really need to be there?” Cuomo asked.
Pisano asked if Cuomo was talking about a particular patient.
“No, literally, I could be talking about hundreds of patients,” Cuomo said. “The insurance companies will not talk to me about the specific cases. How are you supposed to get answers?”
“Well, I think, culturally, it’s not something that companies are attuned to, talking about specific, you know, private patient issues publicly,” Pisano said.
Rehabilitation
Even though United Healthcare refused to authorize payment for in-patient rehabilitation for Dispenza, the hospital provided it to her this fall, anyway. Rosen said the hospital had both a moral and legal obligation to assist her, even without insurance company approval.
Cuomo also filed an appeal on behalf of Dispenza, after she designated him her authorized representative to the insurer. The appeal was written on ABC News stationary and detailed the care the insurance company apparently refused to authorize.
United Healthcare responded to the appeal a month after it was sent.
The company’s response did not directly answer the questions in the appeal, nor did it explain if the company was wrong to refuse authorization for Dispenza’s care.
The letter did, however, state that Dispenza was not responsible for any payment beyond her usual co-payments for the care she received. United Healthcare said in the letter the payment issue was between the company and the hospital.
Going Home
Dispenza said she is lucky, because she received in-patient rehabilitation from Jamaica Hospital, despite Oxford’s refusal to authorize her treatment.
After several weeks of rehabilitation, Dispenza is now getting around with the aid of a walker. She was recently discharged from the hospital and is now home with her sister and her garden.
You did not answer my question, Bill.
Straight up - do you let your family member die because someone else has a better statistical chance with the organ?
You can’t answer that question in this forum, can you? Because you know the answer.
bill’s a paid troll, hon. And no, he definitely is not human.
Too many lizards in the human population.
Straight up - do you let your family member die because someone else has a better statistical chance with the organ?
You do see that this is a stupid question right? Of course, as, say, a parent, I want the organ for MY child. But the parent of the other person wants the organ for THEIR child.
The question is not who the parents want it for. The question, if there is just one organ, is who a neutral third party should give the liver to.
Do you (Richard) actually disagree that if there is just one organ to give out, that it should be given to the person with the best statistical chance for survival with the organ?
Of course not.
I’m sorry to point this out, but it’s a fact this procedure was out of the scope of her coverage. The insurer had evry right and duty to deny the procedure, especially considering her chance of survival. Knowing her condition was worsening as a result of the leukemia, it was the FAMILY’S responsibility to increase coverage, not the provider’s. If anyone is guilty of negligence, it’s them. This is the harsh reality of the situation.
All insurance companies do the same thing, Cigna just got caught. It is sad that human lives aren’t worth anything when it comes down to money. If it was their daughter or relative they would move heaven and earth to do all they could saving no expense. Example Magic Johnson has the money to pay for his treatment and he is doing fine yet those who do not have the money suffer great debt and eventually pass because they couldn’t pay for the care that would prolong or save their life. There shouldn’t be a scope when you pay for a coverage if it is medically necessary. I can understand plastic surgery with the exception of something like going through a windshield being denied. I don’t understand when it is a medical procedure that is needed. What has happened can’t be undone but let not her death be in vain, lets change the health care in this country. I have a bleeding blood disorder simular to leukemia and was told it is chronic leukimia and what just happened to this 17 year old saddens me and scares me. I am over 50 and if her life at 17 wasn’t worth paying for the transplant then I don’t have a chance if I take a turn for the worse. We should all be ashamed and God is watching and he is not forgetting and he says “vengence is mine sayith the Lord, I shall repay.” So I would not want to be in the shoes of big business or standing too close to them when the God of all REPAYS.
I own my pharmacy and I promise that I will not accept any patient with CIGNA!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
This is a sad situation with a young lady having a horrible prognosis for survial with or without the liver transplant. The quoted 65% survival chance is probably for an otherwise healthy person. But this young lady was not otherwise healthy - she had already had cancer, chemotherapy, and mulitple transplants. So the likelihood or her survial would have been much, much lower. Cigna’s response of experiemntal treatment was probably relating to the liver transplant in light of the cancer, and multiple other medical problems as insurance companies cover liver transplants for people all the time.
Everyone seems to think that universal health care is the answer. Keep in mind that this young lady would not have been alive for this battle if she lived in the UK or Cananda. She would never have gotten the lukemia treatment 2 years ago that allowed her to have a 2 year remission - and she never would have been approved for the bone marrow or kidney transplant either. The $20K of estimated cost of ongoing treatment (mentioned in a string above) was not the determining factor for cigna. She would never had survived long enough to get that $20K yearly treatment.
In socialized medicine there are bean counters making life and death decisions all the time - with less money to spread around more people. I’ve seen family and friends get medical care in both UK and Canada - and they don’t get chemo therapy for many cancers - and the chemo protocol and drugs used are from 10+ years ago. My mom had a heart attack in the UK and the drugs and treatment used was obsolete - more than 20 years old - with the effectiveness of aspirin - as stated by her doctor here in the US.
Wake up America - there is no panacea - or free lunch. If we want the best, most modern medical care and we want all stops pulled out when we get sick we have to pay for that. People look at the gross profits of an insurance company and want to know why they couldn’t pay for this young lady’s procedure. If you look at the overall profit margins of most insurance companies you’ll see that they are not making the huge margins that are made by the tech companies, entertainment industry, etc.
We Americans’ have developed this oversized entitlement mentality that we should get the best of everything all the time and someone else should pay for it. Guess what - we are the “someone else” that would pay for universal health care.
Also what most people don’t realize is that most organ transplants do not provide for an unfettered, healthy, normal, long life. It’s often a very limited, sickly and reduced life span - with the likelihood of rejection at any time. With mulitple transplants - even in the extremely unlikely situation of survival - this young lady would have had a very sickly and short life.
It’s very sad to lose someone you love - especially when they are young. But I think anger and frustration are misplaced at the feet of Cigna. There’s a sad fact that sometimes young people get horribly ill and die - and it’s heart wrenching. And sometimes - no matter what - medical science can’t fix it.
As a Transplant Coordinator for Blue Cross and Blue Shield, there is more to this story than meets the eye. The patient had leukemia. Per my company’s medical policy, due to extrahepatic (outside the liver) cancer, the bone marrow transplant would be considered experimental. These cases are reviewed by my company on a case-by-case basis. I reject the idea that this was a denial by the “bean-counter”. For us, when an appeal of a denial is requested, the review on appeal is done by a doctor specializing in transplants. As to murder/manslaughter charges, how do you sentence an insurance company to life in prison? For the death penalty, do you execute just the medical director, or do you also execute the case manager and the person that wrote the medical policy? This is not a criminal law issue. This is a civil courts issue, if the appeal is no longer an option with the insurer or the state department of insurance. Denial of a transplant request does not mean that the patient cannot have the transplant–it just means that, based on the information provided to the insurer, the company is not obligated to pay for it. A protest at Cigna headquarters doesn’t accomplish much. An appeal that Cigna reconsider is the accepted way to overturn the decision. Unfortunately, in this case, the liver function of the patient appears to have declined too rapidly for the system to work. Even if the transplant had been approved, it doesn’t happen until an organ is available. At that point, all is dependant on the allocations of United Network of Organ Sharing. For those that though that getting a liver is a simple process, wake up, smell the coffee, and submit your request for a transplant as early as possible.
Cigna = negligent homicide.
That people are actually defending Cigna sickens me.
Enjoy your race to the bottom line, America.
I’m not definding CIgna - I’m just looking at this as a non-emtionally involved person. My sister is a transplant coordinator at a huge transplant hospiotal in the NYC metro area. She arranges transplants as organs become available. The national transplant network makes very cold calculated decisions every day about who is the best candidate to receive a donor kidney. They pass over people who are not likely to survive - all the time.
For example, diabetics who are in kidney failure never get organs becase by the time the kidneys fail the diabetes has damaged other organs as well - and the prognosis is not good - even with a new kidney. In very cold terms - it’s a waste of a kidney that could otherwise help someone whose only problem is kidney failure and could live a much longer life with a new organ. If it was me or my loved one who was the diabetic in kidney failure I would absolutely want that kidney - but it doesn’t make sense. It’s one of those times when a non-emotionally involved person has to make a decision.
Every part of life requires cold-calculated decisions - and sometimes sad to say - it’s about the life of someone we love. It can involve decisions about pulling a plug, do-not-resucitate orders, or life saving efforts for a sick child. So many people are willing to approve of ending the life of terminally ill senior citizens or unborn babies even up to the 9th month - without a second thought. Life is life - and it’s tragic, sad and heartbreaking when it’s shortened.
I’ve said it before and I’ll say it again - this would not have been an issue under a socialized healthcare systme - becuase the young lady would probably not have had the extra 2-3 years of life that the aggressive chemo got her after her initial diagnosis - and she certainly would not have had the bone marrow and kidney transplants in November. The system in UK
Sorry, but saying she should have gotten the liver remains an indefensible position, given her existing medical condition (with her multiple complications such as coma, and multiple organ failure)
At best, it would have extended her life a short period of time, not cured her.
But there are plenty of liver diseases that are completely _curable_ with a transplant.
And I’m sure that’s where that matching liver went.
It’s clear no one was honest enough with her parents as to just how bad her situation was.
Had someone been honest with them, they would have likely made the same decision as the parents I know who took their infant off the transplant list, after it became clear no doctor had an explanation for the multiple organ failure that finally took his life at 11 months.
Yes, they did make that hard decision to pass up organs in favor of someone who had a better chance than their son.
Shame on doctors, who knew that at best it would prolong the girl’s sufferings for several months and give her family a false hope, but still were trying to make money from her.
I hoped that available liver saved life.
Although its normal for parents and family to want to blame someone when you are faced with the death of a loved one, I seriously doubt they will be able to take Cigna to court for “murder”. We can sit here and blame the insurance for her death because they would not approve the liver transplant or we can face the facts that it was not Cignas decision anyway. If anyone is familiar with the way insurance works it would be easy to see and understand.
Cigna is not the one who in the end had control over what they cover, its the employer that tells Cigna what they are willing to pay for. In the end its the employer that is paying for anything ‘covered’ by Cigna. Insurance companies are just middle men. They just take care of all the details that comes with your insurance plan. The employer that offers the insurance to its employes fund the money to pay claims. That is how this insurance works, that her family had. Its not like the CEO of cigna said he needed another vacation so he wasent going to pay for this girl to live.
Real live doctors looked at her medical records, specialist in transplants reviwed her records and this girls plan PAID FOR by the EMPLOYER would not cover it based on her condition because the procedure was deemed experimental.
Cigna in the end is the one who came back and said they would cover it, at THEIR expense.. not the employers because of the unique situation. Now that sounds like a ‘buisness of caring’ to me. sadly it was too late, but you cant blame cigna for that. you cant really even blame the employer or the family. The tragedy is that this young girl had lukemia and lukemia killed her.
Now saying cigna and insurance companies are just out there to make money, and well yeah, thats right, they are. what kind of buisness would they have if they did not try to make money? what kind of business would any be if they were not out to make a few dollars? That is the way of life. I dont know anyone who would not work to make a pay check.
Its horibble to loose someone to cancer, any form and any age. I know this first hand but i dont blame insurance companies for it, i blame cancer. Cancer sucks, not Cigna.
In the UK you wouldn’t get many transplants if you were overweight let alone a smoker or drinker.
So what if you’re a 17-year-old who’s none of those things, then?
Anyway, how do you know what they would or wouldn’t get? That’s a case-by-case decision anywhere. I personally know a woman who, at 5′2″, 250 lbs, was given a quad bypass in her 40s, in Canada. Nobody told her she couldn’t have it; she needed it,she got it. She’s still alive today; she and her husband are not in debt over it, they didn’t mortgage or lose their home. That’s what medical insurance is supposed to be about. Helping people get well, not helping rich guys get yachts.
The problem is the people in our country who do not have insurance.
You said it yourself: she had insurance. Obviously, it’s not just a problem if you don’t have it. THEY LET HER DIE SO A FEW THOUSAND PEOPLE COULD BE A TINY BIT RICHER. $1.3 million over sixty years? Twenty-some grand a year, divided by how many shareholders and banks and investment funds…? What’s that, a nickel a person? That’s what she had to die for? If you saw a girl drowing but the lifeguard — who was GETTING PAID to help people like her — decided to let her die because he wasn’t going to get his Speedos muddy, would that be okay for you too?
She only had a 65% chance to live
So we sit you in a gas chambre with a revolver on the table. You can get out if you play Russian roulette. If you don’t, we drop the pellets in the bucket. There are two bullets in the revolver. So what do you pick? The 0% gas option? Hmmm, I’ll betcha 65% suddenly sounds like pretty good odds when it’s YOU facing the alternative, huh?
Now imagine we say, “Screw you, you ain’t gettin’ the expensive gun. We’re dropping the pellets”… Plop plop, fizz fizz, oh what a relief it is… to have YOU off our books.
I personally know a woman who, at 5′2″, 250 lbs, was given a quad bypass in her 40s, in Canada. Nobody told her she couldn’t have it; she needed it,she got it. She’s still alive today; she and her husband are not in debt over it, they didn’t mortgage or lose their home. That’s what medical insurance is supposed to be about. Helping people get well, not helping rich guys get yachts.
It was a bypass surgery. Those occur all the time in the US and private insurance covers them as well. However, experimental and speculative treatments are often not covered by either insurance or national healthcare systems. For example, I know of an Australian couple that came to the U.S. for an experimental surgery on their unborn baby after the Australian health care system advised them to get an abortion.
While I support health care reform, I think that Nataline Sarkisyan’s sad story probably should not be the rallying cry. The U.S. health care system already spends too much money on marginal treatments that do little good. Other countries are more judicious about their expenditures, which allows them to cover everyone for less money than in the U.S. I strongly suspect that no national healthcare system would have paid for Nataline’s transplant.
Why didn’t UCLA med center do the transplant for free? They’re supposed to be a non-profit.
Anyone know how may I reach the CEO of Cigna in order to write him a letter about his company’s DISGRACEFUL two denials and its last minute approval of Nataline’s liver transplant. Kinda makes you wonder if that last minute approval was all show - that the “beancounters” at Cigna knew her Natalie’s death was iminent. -GgG
Cigna was the administrator of the insurance, so they were out ZERO dollars whether it was approved or not. They merely followed the contract of what the families employer told them to pay for.
GcG - hats off to Cigna for saying they would pay for it out of their own pocket when they had no responsibility to do so.
It is sad that people make statements like this commentary without first gathering all the facts. CIGNA was not the insurer; it is Nataline’s father’s employer who is the insurer. CIGNA was the insurer’s administrator. Who determines what is covered and what is not? The insurer does; not the administrator.
This commentary wants everyone to believe that CIGNA denied the transplant to save money. Again, CIGNA was just the administrator of a “self-funded” account setup by the insurer. The money saved was not theirs.
This commentary shoots the messenger of bad news. It does not provide the actual facts. Do not believe everything you read in the media. Find out the truth for yourselves before you come to a conclusion.
FYI to the woman who said that diabetics don’t get kidney transplants: I am a diabetic, and on the UNOS list, and hoping to get a living donor transplant sometime this year. The transplant program would not have accepted me if they didn’t think that the rest of my organs were in fine shape. I was tested by many methods in order to gain that approval. I fully expect to get a kidney from the list eventually if I cannot find a compatible living donor, but get one I will. I’m not even 50 and have a lot of living ahead of me still. Other than the diabetes, which is well-controlled, I’m in pretty decent shape.
I am nobody important, not a government official or celebrity or rich person. I am just another diabetic who needs a kidney. The transplant program I’m with does kidney transplants on diabetics all the time, and they go on to lead extended, productive, happy lives. I’m sorry for all the diabetics who have the misfortune of dealing with your hard-hearted sister.
American hospitals/insurance companies seem to feel their responsibility is to their shareholders rather than their patients, and that’s disgusting.
Until they stop seeing healthcare as a business to make money in, nothing’s going to change, and stockholders will cheer every time their dividend goes up, not realizing who’s death has paid for it.
My deepest sympathies to that poor family. I hope a change can come from this tragedy.
And seriously, where were the Terri Schiavo screechers? And good ole’ Jeb Bush?
It’s time to shut these for-profit insurance company death factories down!,
As quoted by the last writer you have this exactly right. I am the daughter of Jo Joshua Godfrey, this is my story that I wrote to legislators when I was 14 years old. No 14 year old American should have ever had to live through this, and I am going to share it with you..
I am 14 years old and I am a victim of medical malpractice. I am writing to the Congress and the Senate because you need to help the victims of medical malpractice. I was ill, my head hurt and my mom took me to the doctor. I had frequent nose bleeds and bad headaches. I think this started in the end of 1992 or early 1993.
They said I was okay, and I remember one doctor was so mean to my mom and me; she didn’t even want to talk about it. She said it was all in my head, that I was okay. 1993 and 1994 were not good years in my life. I was unhappy. My mom was always sick, always in bed coughing, always going to CIGNA getting medicine, always too tired. My mom was not the same mom any more; my head hurt on and off, and I tired not to bother my mom as I could see how ill she was. She was always depressed, always crying, and always moody and coughing. I would yell at her to shut up at night and she kept us all awake, now I feel bad.
In February 1994, I was depressed, my head was hurting, and I took pills from the medicine cabinet, it wasn’t the first time I did this, but my mom was sick she didn’t even notice. Each time I took more and one day my mom came in to wake me up and I wouldn’t get up, I was too tired. My mom said that’s it, get dressed; we are going to CIGNA right away. I went there and CIGNA doctors saw me. They sent me to a mental health place and neither of these two places even knew what I had done. My mom walked me about and I told her what I ad done.
Later that day she said how could she live if I died. My mom cried because she was so tired she blamed herself because she
wasn’t doing enough. I made my mom a promise not to do this again.
My mom called CIGNA and got upset about how they failed to see I had tried to kill myself, asking them what kind of doctors they were. My mom screamed so much they agreed to give me a complete physical. At the physical in early March, we complained so much about my head they agreed to do scans of my head. This went on for about two and a half months, one scan after another, and finally the doctor said I needed to have my sinus washed out, that was in the end of May. My mom asked if this was urgent, did it need to be done right away, the doctor answered it was not urgent. My mom said we would have it done in the summer vacation.
From May to August, my mom got very ill. She went to the doctor and they put her on disability for 6 weeks. In the middle of July, I had a dream that my mom had lung cancer and she was going to die.
My mom got very upset when I told her this. By the beginning of August, my mom sent me to Ireland for one month to visit my grandparents. When I came back from Ireland in the end of August, our home was in an uproar, for 2 weeks CIGNA had refused to give my mom all her x-rays telling her they were lost. She had just got them and it showed she had the lung cancer for almost 2 years. My mom had an operation and 20% of her lung was removed. She had a carcinoid tumor. When my mom was in the hospital, the surgeon told my step-dad he was not well either. It ended up that CIGNA refused to release my step-dad’s records for 2 weeks. When they went to an outside doctor, CIGNA had been treating him for asthma; he really has a very advanced case of COPD and had something on his left lung like my mom had.
We went and got the records for all our family. When we saw mine, and we went to an outside doctor, after going outside doctors I know now what the difference is between a real doctor and a CIGNA doctor is, and I hope maybe one day I’ll get to tell you all about that.
I had a problem where the bone was being destroyed, where the bone was pushing through the orbit, and the doctor said my eye would have been pushed out. I had my surgery at Cedar-Sinai.
1995 is not much better that 1993 as there seems to be no justice for all these things that CIGNA did to us. We want to get the laws changed so no one will ever have to suffer like this again. CIGNA abuses our family to this very day. They make my mom cry for hours and I hope you will let me tell you all about this too. CIGNA should also know if my parents die, where will I go, and what will happen to my brother and sisters? I’m an American, and when I grow up, I don’t want to live here. I want to move to where people are good and kind. I’ll move to Ireland.
Now I am 28 Years old. However it is pretty sad that any family would have had to suffer this way, and these crooks and swindlers escaped punishment in the State of California.
THANK YOU CIGNA GLENDALE