Contra Costa Times, CA
Dec 5 2007

Denial of transplant fuels push for reform

Case is perfect example of need for changes in health care, advocates
say

By Susan Abram
MEDIANEWS STAFF

Article Launched: 01/05/2008 03:00:49 AM PST

They all still mention her name — family and friends, health care
professionals, even presidential candidates — evoking her story as
an example of health insurance gone awry in the United States.
The case of Nataline Sarkisyan of Glendale, whose insurer recanted
its denial of a liver transplant just hours before her death, is at
the center of the national controversy about health insurance and how
to reform the system.

Some, including high-profile attorney Mark Geragos, who is
representing Nataline’s family, believe the public outcry, as well as
the threat of a civil lawsuit against CIGNA Health Care, will spark
changes in policies and procedures within the insurance industry.

"One of the reasons why we’re pursuing an investigation is that the
only thing that will shake them up is a penalty," he said.

But others say the insurance industry will be guided by its financial
bottom line rather than by public anger over the case or civil
penalties.

"Unfortunately in this case, I’m not convinced a lawsuit, even a
successful one, would change the underlying business process," said
Gerald Kominski, associate director for the Center for Health Policy
Research at UCLA.

"There may be changes made to the timeliness of the decisionmaking,
but an insurer is always within their ability to make determinations
on whether or not a specific treatment is considered experimental."

Nataline had been treated for recurrent leukemia since age 14 and had
hoped to receive a liver transplant after doctors at UCLA Medical
Center said the procedure to extend her life.
Dr. Jeffrey Kang, CIGNA’s chief medical officer, released several
statements saying the insurer denied authorization after consulting
with two independent experts who said the transplant would not be
effective or appropriate.

After Nataline’s case was publicized by her family over the Internet
and taken up by the California Nurses Association as well as the
Armenian community, CIGNA reversed its decision.

By that time, the teen’s family had removed her from life support,
and she died just hours after.

Within the insurance industry, public demand and political backing
can play a big role in decisionmaking, said Mohit Ghose, spokesman
for America’s Health Insurance Plans, a trade group that represents
major insurance companies.

While he said he wasn’t familiar enough with Nataline’s case to know
how it will impact policy, he noted that public outcry doesn’t always
mean consumers receive the best in health care.

In the 1990s, several states forced insurance companies to cover a
certain breast cancer treatment. Years later, it was determined that
the treatments were useless, Ghose said.

"One of the things that we have seen in our industry is there has
been a great deal of attention to public demand," Ghose said. "That
is important because it keeps us out of the courts. It’s an
unfortunate situation that we are paying 10 percent more because of
the failed liability system."

Both Kominski and Ghose said what does help is for consumers to file
complaints against insurers who deny treatment, medications, or who
pull coverage altogether.

Filing complaints "absolutely does help," Kominski said.

"What we’ve seen is changes in requirements for HMOs, for example,
regarding the availability to provide translators. That is directly
in response to consumer complaints."

During the past several years, the California Department of Managed
Health care has compiled consumer complaints against HMOs, which
includes access to care, benefits and coverage, claims and financial
issues, enrollment, coordination of care, attitude and service of
health plan, and attitude and service of health care provider.

The agency said complaints have declined slightly, from 4,186 in 2005
to 4,025 in 2006.

But those complaints that stem from coordination of care, which would
include such procedures such as liver transplants, have gradually
increased, from 590 in 2005 to 628 in 2006.