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Sunday, December 23rd 2007

Would Single Payer Have Saved A Patient Requiring Liver Transplant?

This is one of the worst stories I’ve ever heard. A girl goes into liver failure, is sent by her insurer to get evaluated for a transplant. Then develops complications and the insurer denies the transplant despite the organ sharing network having found a match for her. Then just hours after her family has taken her off life support, they learn the insurer has changed their mind.

The case of a Northridge teenager taken off life support just as her insurance company reversed itself and agreed to pay for a liver transplant is highlighting tensions among physicians, patients and insurers over the definition of experimental procedures.

About 4:40 p.m., just as Sarkisyan said the family had decided to remove Nataline from life support, Cigna sent a letter to the family’s attorney approving the transplant.

The letter, faxed to attorney Mark Geragos, is stamped 4:44 p.m. Geragos said his staff tried unsuccessfully to reach the Sarkisyans at the hospital. The family said they didn’t see the letter until after they removed Nataline from life support at 5:20 p.m.

“They took my daughter away from me,” Krikor Sarkisyan, 51, an automotive technician, said at the news conference outside Geragos’ downtown L.A. office.

The trouble was two-fold. First, the procedure was considered ‘experimental’ and the family had not purchased a plan to cover such. Basically it failed to reach some mystery threshold of evidence in the literature, the guidelines for which probably only exist in some dark room at CIGNA HQ. Second, she had a gross 65% survival rate at six months.

Dr. Goran Klintmalm, chief of the Baylor Regional Transplant Institute in Dallas, said the operation that UCLA wanted to perform was a “very high-risk transplant” and “generally speaking, it is on the margins.”

But Klintmalm said he would consider performing the same operation on a 17-year-old and believes the UCLA doctors are among the best in the world.

“The UCLA team is not a cowboy team,” he said. “It’s a team where they have some of the soundest minds in the industry who deliver judgment on appropriateness virtually every day.”

I think the aftermath of this tragedy, by some of the groups who have latched on, is a really lovely demonstration of America’s expectations for health care versus their complaints about cost.

A representative for America’s Health Insurance Plans had the best quote to summarize the voices that should be favored in making health care decisions,

“The transplant was recommended by the medical professionals at the bedside,” [Karen] Idelson said. “They should have been listened to.”

Keeping the bueacrats out of health care decisions costs money. Demanding absolute deference to the physicians in a controversial case like this while also expecting low health care costs or pining for health care hand outs is incompatible. For instance, while certainly not even attempting to make a judgment in this case, the issue of coverage for experimental therapy.

In such a battle of costs versus expectations, the California Nurses Association made a particular ass of themselves,

The California Nurses Assn. publicized Nataline’s case, calling it an illustration of the need to abandon private insurance coverage in favor of a single-payer plan.

The reality is that Natalie would’ve almost certainly been less likely to get a liver transplant under a single payer system. An ‘exponential’ (I use that as hyperbole) increase in rationing is the trade off you make with health care systems with global budgets. Never forget that.

With a 65% chance of survival at six months, there’s almost no way that the bureaucrat in charge of a global budget for health care, with funds for a limited number of liver transplants this year and a list of patient’s all with better outcome potentials, would be more likely than an official of greedy CIGNA in authorizing this surgery.

Consider the UK Department of Health’s guidelines on liver transplants as an example,

[C]urrent recommendations indicate that patients with less than 50% probability of surviving five years after liver transplantation should not be placed on the waiting list.

What distinguishes these guidelines from say those of a private non-profit organ sharing network, is that these are made by the people holding the only purse strings.

But that’s beyond the tragedy of this case.

On point, I think it is disturbing the rhetoric that is coming about now, especially from Mark Geragos (yeah, the same guy).

Now the Sarkisyan family hopes manslaughter or murder charges will be pressed.

Their lawyer, Mark Geragos, says he will refer the case to prosecutors for possible criminal charges against the insurer, Cigna HealthCare.

What? I mean a lawsuit is in order and I hope, should the facts support the current story coming out, that they kick CIGNA’s ass. But criminal charges? I suppose if it was my daughter I might wish the same…but taking a step back you’ll never get me to admit that philosophically a crime of omission should ever be tantamount to a crime of commission. Be careful with this, next thing you know they’ll be making criminal judgments about physicians’ care decisions.

“Oh, he was influenced by a sales rep to use these screws for the fusion even though I have this case report of them failing! Now my client is paralyzed. This doctor was motivated by greed and what he did constitutes assault.”