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Insurer Denial Revives Argument Over Health Care Access

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  • Insurer Denial Revives Argument Over Health Care Access

    INSURER DENIAL REVIVES ARGUMENT OVER HEALTH CARE ACCESS
    By Susan Abram, Staff Writer

    Los Angeles Daily News, CA
    Jan 6 2007

    They all mention her name - family and friends, health-care
    professionals, even presidential candidates - evoking her story as
    an example of health insurance gone wrong in the United States.

    The case of Nataline Sarkisyan of Northridge - who died last month
    after her insurer denied, then agreed to, a liver transplant hours
    before her death - continues to highlight the national controversy
    about insurance and medical care and what, if anything, can be changed.

    While overall complaints against some California insurance companies
    about everything from access to care to other services have declined
    in the past two years, complaints about more specific procedures -
    like Nataline's - have increased, according to a Daily News review
    of state data.

    And patients asking for independent medical reviews - the official
    process of seeking a second opinion - have jumped 13percent in that
    time, according to the data.

    It remains to be seen what kind of impact those complaints will have on
    the system, but Nataline's death has reignited a heated public debate
    about the effectiveness of the nation's health care insurance process.

    "Just a few weeks ago in America, Nataline Sarkisyan, a 17-year-old
    girl, ... needed a liver transplant, and (her) insurance company
    decided they wouldn't pay for her liver transplant operation,"
    Democratic presidential candidate John Edwards said last week after
    placing second in the Iowa Caucus.

    "Ultimately, the American people spoke up on her behalf by marching
    and picketing in front of her health insurance carrier. And, finally,
    the insurance carrier caved in and agreed to pay for her operation.

    And when they notified the family just a few hours later, she died.

    She lost her life. Why? Why?"

    Some, including high-profile attorney Mark Geragos, who is representing
    Nataline's family against the insurance company, CIGNA, think the
    public outcry and the threat of a civil lawsuit and possible criminal
    charges will change policies and procedures.

    "If you're driving a car and you have an accident and you kill someone,
    you could be charged with murder," Geragos said. "Why wouldn't the
    same happen with insurance companies?

    "You want to change behavior so that the public gets what the public
    deserves."

    But others say the public outcry and pending lawsuits in Nataline's
    case will do little.

    "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 decision-making,
    but an insurer is always within their ability to make determinations
    on whether or not a specific treatment is considered experimental."

    While he said CIGNA might have used bad judgment in Nataline's case,
    Kominski said insurers can't cover every single treatment for every
    single patient because they need to stay financially viable.

    "I'm not sure it's a good idea to write a blank check to anyone,"
    he said.

    Nataline had suffered from recurrent leukemia since age 14. Her effort
    to receive a liver transplant gained the national spotlight via the
    Internet; and the California Nurses Association, as well as many in the
    Armenian community, staged protests at CIGNA offices around the region.

    Dr. Jeffrey Kang, CIGNA Health Care's chief medical officer, released
    several statements saying the company had done all it could for
    the teenager, who died after twice being denied authorization for
    a liver transplant, even though doctors at UCLA Medical Center said
    the procedure could save her.

    Kang said the insurer's initial denial of the transplant was made
    after "we went directly to not one, but two independent experts
    in the field who agree that the procedure in question, given the
    patient's particular circumstances, would not have been an effective
    or appropriate treatment."

    Still, the company reversed its decision out of empathy and public
    demand, though it still maintains it was not the right decision.

    Within the insurance industry, public demand and political backing
    can play a big role in decision-making, 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 might affect policy, he noted that public outcry doesn't always
    mean consumers receive the best health care.

    In the 1990s, for example, patients pushed for insurance companies
    to cover a certain type of procedure called autologous bone marrow
    transplants for women with late-stage breast cancer.

    But years later, research found it was only helpful in a small
    percentage of women, Ghose said.

    Still, both Kominski and Ghose said some helpful changes have come
    about in the wake of consumer complaints against insurers who deny
    treatment or medications or who pull coverage altogether.

    "What we've seen is changes in requirements for HMOs, for example,
    regarding the availability to provide translators," Kominski said.

    "That is directly in response to consumer complaints."

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

    Since 2002, the number of complaints has slightly decreased - from
    4,186 in 2005 to 4,025 in 2006.

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

    And patients seeking independent medical reviews also have increased,
    from 989 in 2005 to 1,119 in 2006.

    "Most people don't know about an independent medical review, or the
    availability through the state, to know," department spokeswoman
    Lynne Randolph said.

    In December, California Insurance Commissioner Steve Poizner announced
    his department was seeking $12.6million in fines and penalties
    against health insurer Blue Shield for more than 1,200 violations,
    half of which were related to improper rescinding of coverage from
    2004 and 2005.

    Poizner issued the penalty based on a review of Blue Shield that was
    launched because of an increase in consumer complaints, said Molly
    DeFrank, spokeswoman for the California Insurance Department.

    Allegations included failure to pay claims on a timely basis, failure
    to provide required information when denying a claim and mishandling
    of member appeals.

    A Blue Shield spokesman said the company agrees with the overall
    independent review and regulatory processes, though not with all of
    the allegations.

    "There were a number of instances we took corrections on," Blue Shield
    spokesman David Seldin said. "We think that's the way the Department
    of Insurance should work."

    In Nataline's case, some have questioned why physicians at UCLA didn't
    sidestep CIGNA's decision and move ahead on their own with the surgery.

    "All health-care organizations are faced with trade-offs between
    the cost of providing care and who is going to be providing care,"
    Kominski said. "It is a difficult trade-off we make in society.

    Physicians are placed in a difficult position."

    And it's a situation that registered nurse Zenei Cortez said she sees
    all the time.

    As one of the board presidents for the California Nurses Association,
    which helped organize a public rally about Nataline's case, Cortez
    said any attention cast on how patients are treated will make the
    public more demanding.

    On the job, she said, she sees patients literally pushed out the door
    because their insurance doesn't cover overnight stays.

    "As a nurse, it goes against my moral values and humane values,
    against the pledge taken advocating for my patients," she said. "But
    I have my hands tied."

    If anything, Nataline's case will "send out a strong message to the
    public that if we do not take a step or force our legislatures to
    universal health care, this is going to continue on."
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