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."