Guest guest Posted January 10, 2008 Report Share Posted January 10, 2008 This article is long but fascinating. I believe it contains much food for thought as we ponder the San situation. Sometimes things are not as simple as we would like them to be. Gene G. http://www.healthbehttp://www.http://www.hhttp://www.http January 02, 2008 Bad Cases Make Bad Law Perhaps you saw the headlines over the holidays: • “CIGNA Defends Decision To Let Teen Die—On Christmas Eve†• “As CIGNA Insurance Waffles on Liver Transplant, Girl Dies†• “Lawyer: CIGNA's refusal to pay for liver transplant 'killed' teen†• “Teenage Girl Dies So CIGNA Execs Can Get Richer†• Metroblog: " Merry ******* Christmas, From CIGNA Healthcare " Without question, this is a tragic story. Here are the bald facts: Nataline Sarkisyan, a 17-year-old who had been battling leukemia for three years, rece ived a bone marrow transplant from her brother the day before Thanksgiving. She then suffered complications; her liver failed, and she went into a coma. At that point her doctors at the UCLA Medical Center recommended a liver transplant, saying that the transplant would give her a 65 percent chance of living another six months. Within four days, a matching donor was found. But on December 11th her insurer, CIGNA, refused to cover the transplant on the grounds that for a patient this sick, the transplant would be an “ experimental procedure.†And her insurance policy " does not cover experimental, investigational and unproven services.â€Â The doctors told the family that their only alternative would be to make a $75,000 down payment on the operation. Unfortunately, the family didn’t have $75,000. Observers both in the mainstream media and in the blogosphere were outraged when they heard that CIGNA had denied coverage. Daily Kos led the protest with “Murder By Spreadsheet: CIGNA Denies Claim and 17-Year-Old Will Die.†Responding to the firestorm, on December 20 CIGNA relented, saying that " despite a lack of medical evidence regarding the effectiveness of such treatment,†it would cover the transplant. The letter from CIGNA came too late. That same day, the hospital called to say that Nataline's condition was deteriorating and her family was forced to make the decision to take her off life support. She died within the hour. The next day the Sarkisyan’s lawyer announced that the family planned to sue CIGNA for “malicious†murder. This is both a tragic tale and a complicated story—far more complicated than the headlines suggest. As Dr. Ford, an assistant professor at UCLA’s medical school observed on his blog, California Medicine Man, “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.â€Â Here are just a few of the questions that this vexed and vexing case raises: • Set aside CIGNA’s concerns about the cost of the operation, and consider the risks and benefits for the patient. Does it make sense to put a 17-year-old through the trauma of an organ transplant if her best hope would be another six months of pain while she struggled to recover from the operation? • Did her parents have an opportunity to share in the decision about the transplant or did they simply consent? In other word, were they given a choice: did they share in the process of making the decision while weighing the risks, the possible benefits, and the likely side effects? (See my post on shared decision-making here and a longer article on the same topic here). One would like to know what Nataline herself wanted, but she was not in a position to express her wishes. Her mother told reporters that she had been in a vegetative state for weeks. • What does one make of the research here, which suggests that the UCLA Medical Center consistently provides much more aggressive treatment than many other hospitals--while achieving no better outcomes than medical centers that practice more conservative medicine? • Finally, if Nataline had lived in a country with a single-payer health care system—a country where the payer was not concerned about profits, would she have received a transplant? Begin with the most important question: when Nataline’s UCLA doctors recommended a liver transplant, were they suggesting futile, end-of-life treatment? On his blog, “California Medicine Man, " UCLA’s Dr. Ford does not pretend to have a final answer, but he does raise some pertinent issues. Let me stress, first, that Ford, who is a full-time assistant professor at the UCLA School of Medicine, was not involved in Nataline’s case. Nevertheless, he notes “I was very surprised that the family's physicians claimed a 65% six month survival with the transplant. It seems highly unlikely that such data, if it exists at all, has any degree of reliability. These are rare cases. I think it's interesting that these doctors are now refusing to speak to the press and I wonder how excited they'd be at having to defend those numbers publicly. â€Â To be fair, in the face of impending litigation, it is not surprising that Nataline’s doctors are not talking-- but it does make it very difficult to get information on the medical evidence behind their recommendation. Here it should be noted that Ford’s blog stipulates that his views are his own and do not represent those of UCLA, Harbor-UCLA Medical Center or the Los Angeles County Department of Health Services. And he is not a transplant specialist; he works in the General Internal Medicine Division where he teaches medical students, interns and residents. But when the L.A. Times and the Associated Press asked physicians who are transplant specialists about Nataline’s case, their answers were equivocal--at best: Dr. , chief of the transplant service at UC San Francisco told the L.A. Times that his center “generally will not accept a patient without a 50% chance of living five years...†But, according to the letter UCLA's doctors wrote to Cigna, a patient like Nataline might, at best, live six months. It might seem cruel to say that it’s only worth doing the operation if the patient has a chance of living at least five years. But it is also cruel to put a patient through the pain and extraordinary trauma of an organ transplant if the best outcome the doctors promise is another six months of poor quality life. " The problem that they got into is, here's a situation where she didn't have very long to live, " Dr. observed. " Probably in this situation, they're probably better off to say, 'The transplant center really feels like this is the right thing to do, let them go ahead.' " In other words, his center would not accept Nataline as a transplant patient because, from a medical point of view, the possible benefits just aren’t enough to justify the risks to the patient. But also seems to be saying that, given the fact that she was going to die anyway, CIGNA probably should just have said “go ahead.†The standard of care for this particular situation is " going to be pretty hard to know, " added. " I think it's a very difficult decision for both the transplant center and the insurance company. " Another transplant expert, Dr. Goran Klintmalm, chief of the Baylor Regional Transplant Institute in Dallas, called the operation that UCLA wanted to perform “a very high-risk transplant and generally speaking, it is on the margins. †But Klintmalm also told the L.A. Times that 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. "  Translation: in Dr. Klintmalm’s professional opinion this operation is “on the marginsâ€â€”but he wouldn’t want to criticize his medical brethren at UCLA. Talking to the Associated Press, Dr. Stuart Knechtle, who heads the liver transplant program at the University of Wisconsin at Madison, was more definite: “Transplantation is not an option for leukemia patients because the immunosuppressant drugs [that the patient needs to take so that he or she does not reject the organ] tend to increase the risk and growth of any tumors, " Knechtle declared. “The procedure would be futile, " he added, although the Associated Press notes that he was not commenting specifically on Nataline’s case. I wonder if Nataline’s parents had an opportunity to solicit second opinions from doctors at other hospitals—and whether Nataline’s doctors were clear in spelling out why some transplant physicians might disagree with their recommendation. Too often, physicians “seek informed consent simply by presenting a scenario along the lines of ‘here's what we have to do, and why,’†observes UCLA’s Dr. Jerome R. Hoffman, lead author of an article on informed decision making published in PloS Medicine last year. “This may or may not be accompanied by a brief mention of the possible risks of the proposed strategy, and in rare cases, even by a very brief mention of potential alternatives—although this last element would typically be followed by a description of why such alternatives are not really reasonable.†I also wonder if the hospital made a palliative care specialist available to talk to the parents, or if they relied solely on the advice of the surgeon and other doctors who had been treating her when she developed complications? The fact that Nataline’s case had gone sour on her doctors’ watch might have made them less than objective. I’m not suggesting that the doctors were worried about a malpractice suit: following bone marrow transplants, patients are very susceptible to complications. There is no indication that the physicians caring for her did anything wrong. Nevertheless, at least one prominent palliative care specialist has told me that sometimes she has to protect patients from surgeons who want to try to repair a failed procedure —with yet another surgery. “They can’t bear the failure—they want to make it right. This is what they have been trained to do.†But they are not necessarily thinking about what is best for the patient. And, according to research done by investigators at Dartmouth University, UCLA has a record of over-treating some of its sickest patients. In a study of how patients suffering from twelve chronic illnesses (including cancer) fared during the final two years of life , the research compared UCLA to eleven other academic medical centers and found that, in most cases, UCLA provided far more intensive, aggressive care. For example, “Compared to [patients] treated at UC San Francisco [a sister hospital], UCLA patients spent 45 percent more days in acute care hospitals, used 3.5 times more days in intensive care and were 1.5 times more likely to have been admitted to an ICU during the hospitalization in which they died. They experienced 71 percent more physician visits and 37 percent more frequent referrals to ten or more different physicians. Yet, despite more aggressive care at UCLA, “objective quality measures showed that the quality of care was as good--and by some measures better—at UCSF.â€Â The article, which was published in Health Affairs, cited another major study showing that patient satisfaction was higher at UCSF. Why do patients receive more intensive, expensive treatment at UCLA? The answer confirms what three decades of Dartmouth research has shown: UCLA medical center boasts an abundance of hospital beds and specialists. As Dartmouth’s researchers have found, time and again, where there are more specialists and more beds, patients receive more aggressive care. This is not intentional, it is simply a fact: if the beds are available, they will be filled. If the specialists are available, they will be called in to consult on the case. And each specialist will recommend yet another procedure. This is why it costs Medicare twice as much when a patient is treated at UCLA as when a very similar patient is cared for at the Mayo Clinic. Meanwhile, outcomes, patient satisfaction and doctor satisfaction are all higher at Mayo. “UCLA knows that it has a problem,†Dr. Jack Wennberg, the father of Dartmouth’s research told me after this report on California hospitals came out. “What do they plan to do about it?†I asked. “What can they do?†Wennberg replied. “They can’t fire the specialists and close down the beds. They need those specialists and those beds to generate the revenue stream they must have to service their debt.â€Â So, for the time being at least, supply will continue to drive demand. The case becomes even more ambiguous if you look at CIGNA’s record on transplants. Since CIGNA is a for-profit insurer, most of its critics assumed that the company refused coverage simply because the operation was expensive. But the L.A. Times reports that CIGNA has a record of approving coverage for more than 90 percent of all transplants requested by its members, as well as more than 90 percent of the liver transplants. Some of CIGNA’s critics also assume that, “if only we had single-payer system in the U.S., these things wouldn’t happen. But the truth is that had Nataline lived in the U.K., the chances that the government-sponsoreSome of CIGNA’s critics also assume that, “if only we had single-payer system in the U.S., these things wouldn’t happen. But the truth is that had Nataline lived in the U.K., the chances that the government-sponsore<wbr>d healthcare system would have approved her transplant are slim. And, as Ford (a.k.a. California Medicine Man) points out, it’s not likely that she would have received the transplant in Canada either. “I’vfewer.†In these countries, the government considers the cost-effectiveness of treatments, and no one, not even Nataline’s doctors, has suggested that the transplant might have given her even one or two extra years of healthy life. As Ford observes, the governments in single-payer countries must face the fact that when they spend money (and a liver) on one patient, they won’t have that money (or liver) to spend on someone else: “Every dollar spent represents a dollar that could have been spent elsewhere. Everything in medicine and economics is a trade-off...Everything in medicine and economics is a trade-off...<wbr>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?†asks Ford. “And if such is the case, can these individuals not recogniz Finally Ford raises a troubling question: “Why didn't UCLA, the patient's hospital, simply perform the surgery and defer payment from the family or CIGNA until later? If it was such a great idea, why didn't they exhibit the outrage and strength of conviction to go ahead regardless of CIGNA's assessment? “Surely an institution of this size could have absorbed these costs at least until the finances could later be sorted out,†Ford continues. “This is all the more true given that most such costs are fixed costs that the hospital would incur regardless of whether this particular operation was performed or not. “How is it that the hospital and the doctors' moral standing in this disaster has escaped media attention? My prediction is that eventually, it won't.†“Ultimately, CIGNA made a mistake in relenting,†Ford concludes.â€One of the biggest mistakes CIGNA may have made was giving in to the public relations consequences and actually approving the procedure (belatedly).â€Â He notes that CIGNA reversed itself “despite the lack of medical evidence regarding the effectiveness of such treatment.†“To me, this is very telling,†Ford writes. They've all but admitted that the decision to capitulate was based not on science but on emotion.†Ultimately, no doubt, CIGNA will agree to an large out-of-court settlement .. The case has been tried in the press—by people who know little or nothing about Nataline’s condition, her chance of surviving the surgery, and what suffering she would have faced if she had survived the surgery. Yet I hope that CIGNA settles out of court. I would hate to see this case come to trial, because, in such an emotional case, the jury almost certainly would rule in the family’s favor—setting a bad precedent. In the future, physicians would be even more likely to feel obliged to recommend “marginal†end-of-life treatment, and insurers would be more likely to cover it. Bad cases make bad law. And this is a bad case because it is so ambiguous and so fraught with emotion. Meanwhile there are so many clear-cut problems in our for-profit private insurance industry that should be investigated in a court of law. I would like to see states take insurers to court for the way they “cherry-pick†their customers, shunning the sick, and raising premiums on customers who become seriously ill. Often, insurers scour their records looking for some scrap of evidence that the patients’ illness may have been caused by a pre-existing condition. Insurers also write policies in such a way that it is very difficult to know, for certain, what will be covered—and they advertise “super-saver†policies that contain so many holes that they don’t even deserve to called “insurance.†These are good cases that could lead to good laws. By contrast, questions about end-of-life care should not be decided by lawyers and juries. Nor should they be decided by insurers. They should be left to physicians, palliative care specialists and medical ethicists, keeping in mind that the physicians treating a dying patient may not be in the best position to decide when it’s time to stop. In other developed countries, national guidelines help steer these decisions, with an eye to what is cost-effective—and what is humane. Posted by Maggie Mahar on January 2, 2008 | Email this post Start the year off right. Easy ways to stay in shape in the new year. ************** Start the year off right. Easy ways to stay in shape. http://body.aol.com/fitness/winter-exercise?NCID=aolcmp00300000002489 Quote Link to comment Share on other sites More sharing options...
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