Deadly Spin

by Wendell Potter

  This time, her doctors said, chemotherapy wouldn’t be enough. She needed a bone marrow transplant, and it turned out that her older brother, Bedig, was a perfect match. He gladly agreed to be the donor, and CIGNA agreed to pay for it, as long as the procedure was done at a hospital in CIGNA’s network, Mattel Children’s Hospital at UCLA.

  “We rushed to get Nataline admitted because timing is so important,” Hilda said. Nataline had to have the bone marrow transplant within a few days of a heavy dose of chemotherapy.

  Although Nataline knew her leukemia was back, “you would never have thought she was even a little sick,” her mother said. “She walked into the hospital smiling, knowing she would go back home soon. She looked like she was in perfect health.”

  IT WAS THE BEGINNING … OF THE END

  Nataline was admitted on Monday, November 12, 2007. Across the country in Philadelphia, I, too, was having a busy, stressful Monday, starting with an eight A.M. Public Policy Council meeting at which CIGNA’s lobbyists in Washington briefed my boss (general counsel Carol Ann Petren) and me on the latest talk on Capitol Hill and in the presidential campaigns about health care reform. Immediately after that, I met with one of the company’s securities lawyers about a Securities and Exchange Commission filing. At one P.M., I was off to the boardroom on the seventeenth floor for an important briefing on CIGNA’s Investor Day, which would be held the following Friday at the Mandarin Oriental Hotel in New York. Because the company expected Investor Day to go well—we had told investors and analysts a few days earlier that we expected the company to earn more than a billion dollars by the end of the year—I was asked if I could get a reporter from the Wall Street Journal to cover it.

  Nataline’s bone marrow transplant, eventually performed the day after Thanksgiving, went well, but serious complications soon developed, especially in Nataline’s liver, stemming from the heavy chemotherapy infusion and accompanying radiation and the transplant itself. A week after the procedure, her doctors said she had to have a liver transplant.

  In early December, not long after CIGNA’s Investor Day, which had cost $250,000 ( just feeding the 150 investors, analysts, and CIGNA executives at the six-hour meeting had cost $60,000), Nataline was taken to the ICU, where she would wait for her new liver. Knowing that insurers normally require prior authorization—a liver transplant costs about $250,000, or the same amount CIGNA had just spent in New York—her doctors contacted CIGNA’s transplant unit and asked for approval.

  It never occurred to the Sarkisyans that there would be problems. The biggest worry they had was whether a liver would become available and be a match for Nataline. Early in the morning a few days later, Hilda got the call she had been praying for. “Put on your best outfit, because we have the perfect fit for your daughter,” she recalls one of the doctors telling her.

  Because it was the Christmas season, Nataline’s favorite holiday, Hilda decided on a red outfit and rushed to the hospital, grateful that Nataline would soon be getting the liver to save her life. She was stunned when one of her daughter’s doctors pulled her aside and told her, “Hilda, we have a liver, but we don’t have clearance from CIGNA.”

  “What are you talking about?” she asked him, not understanding why CIGNA would have a say in the matter. “We have insurance, and I know it covers transplants, so what kind of clearance do you need?”

  Nataline was covered under a policy that her father had obtained through Mercedes-Benz, where he worked as a technician. CIGNA administered the health care benefits for the company’s employees and their dependents. It was a self-insured account—Mercedes-Benz, rather than CIGNA, assumed the risk—a fact that had seemed of little consequence at the time but that the Sarkisyans would soon learn was of enormous consequence.

  Nataline’s doctors told the Sarkisyans that before they could get approval to proceed with the transplant, they would have to do a biopsy of Nataline’s liver to satisfy a request received from a CIGNA medical director. The Sarkisyans felt they had no choice but to agree to it. “They had to cut her and get a piece of her liver just to prove to CIGNA that she needed a transplant,” Hilda said.

  By the time this procedure was done, however, the liver that had been a perfect match had had to be given to another patient. The family now could only wait—and pray—for another one.

  Another liver did become available a few days later, but the Sarkisyans were in for yet another shock: CIGNA refused to pay for the liver transplant, even though her doctors said it was her only hope for survival—and even though the procedure CIGNA had demanded had proved that her liver was indeed failing. A CIGNA medical director sent a message to Nataline’s doctors at UCLA, where hundreds of transplants are performed every year, saying that the transplant for Nataline, in his view, would be “experimental.”

  It had never occurred to the Sarkisyans that their daughter’s fate would be in the hands of someone whom they had never met and who had never laid eyes on their daughter, much less personally examined her or assessed her condition.

  When Nataline’s treating physician, a professor of pediatrics in the Division of Gastroenterology, Hepatology and Nutrition at UCLA, submitted his original request for prior authorization, a CIGNA transplant case manager in Pittsburgh began the process of reviewing Nataline’s medical records and the Sarkisyans’ benefit plan. Three days later, she recommended that CIGNA cover the transplant. However, because Nataline by then had developed a lung infection while in the hospital and was very weak, the case manager asked the medical director of CIGNA’s transplant unit to look at the case.

  The medical director denied the request from Nataline’s doctors, noting that the Mercedes-Benz benefit plan did not cover “experimental, investigational and unproven services.” In his opinion, a liver transplant for someone in Nataline’s rapidly declining state of health would fall into that category.

  Within hours of receiving this denial, Nataline’s treating physician and three of his colleagues at UCLA pleaded for him to reconsider, insisting that the requested transplant would not be experimental. They contended that similar patients had been shown to have a sixty-month survival rate of approximately 65 percent.

  Despite the doctors’ plea, CIGNA was not persuaded that there was enough documented evidence that a liver transplant for someone in Nataline’s condition would be appropriate. The company stood by its decision. In communicating that it was upholding the denial, CIGNA said that the lung infection and other problems that had developed since Nataline had been admitted to the hospital would be unlikely to result in a successful outcome for Nataline and that, consequently, the surgery would not meet CIGNA’s definition of medical necessity. Who was right? The reality is that in many cases, no one ever knows. If a critically ill patient dies after an insurance company refuses to pay for a doctor-ordered procedure, which often happens, it can never be proved that the patient would have even survived the procedure.

  THE FAMILY FIGHTS BACK

  The Sarkisyans were devastated when they got the news that CIGNA wouldn’t cover the transplant—but they were not about to give up hope, Hilda in particular. She believed that she and her friends in the Armenian community might be able to mount a campaign to shame CIGNA into approving the transplant. So she immediately began contacting family and friends in the close-knit community in Los Angeles and asking them to do anything they could to draw public attention to Nataline’s plight.

  Nataline’s godfather started making calls to reporters and TV news producers throughout L.A. and the San Fernando Valley, where the Sarkisyans live. The TV reporter who left that first voice mail message for me had just talked to him. (The information that the Sarkisyans owned a second home—actually a rental property—apparently came from a hospital employee who noticed that Nataline’s mother had listed it among the family’s assets on a form the hospital had asked her to fill out when Nataline had been admitted. Whether CIGNA had access to that information is unclear, but the company denied that the family’s rental property
was a factor in its decision.)

  Nataline’s story likely would have stayed local had it not been for the California Nurses Association, a politically active and media-savvy union that represents thousands of nurses throughout the state. A co-worker of Hilda’s who had been a nurse contacted CNA’s leadership in Oakland and asked them to get involved in the Sarkisyans’ campaign. It didn’t take much arm-twisting. CNA spokeswoman Liz Jacobs said the organization never considered not doing all it could do for Nataline.

  “We’ve taken our oath to be patient advocates,” she said, “and we will be advocates wherever the need takes us. So we were up for this.”

  Early on Thursday morning, December 20, CNA blanketed the media with a news release announcing a protest that would be held at eleven A.M. that day in front of CIGNA’s California headquarters, in Glendale, which happens to be in the heart of the Armenian American community. The headline was sure to get the media’s attention: “Life Denied: Nurses, Family of Sick Teen March on Health Insurance Company; 17-Year-Old Girl Needs Liver Transplant, CIGNA Denies.”

  “My daughter survived two bouts of cancer,” the release quoted Hilda as saying, “and against all odds has been stable even with so many of her organs not working, only to now be told that she cannot get the only treatment that will save her life because some administrator in some office thinks it is too expensive. We needed help in standing up against this insurance provider, and of course it was the nurses who stepped forward.”

  My phone started ringing off the hook as soon as the nurses’ release went out. I knew I had a crisis on my hands when calls poured in not only from local TV and radio stations but also from the Los Angeles Times, CNN, and NBC—and even from the general public. The release, which was posted on the home page of CNA’s Web site, also appealed to the public to call CIGNA demanding that it “provide the care Nataline needs.”

  The nurses were also making a political statement with the protest. The California legislature was embroiled in a debate on reforming the state’s health care system, and CNA, which has long supported a single-payer system that would ban private insurers, cited Nataline’s situation as a reason why state lawmakers should reject a reform plan supported by Governor Arnold Schwarzenegger and some legislative leaders.

  “CIGNA’s refusal of Nataline’s liver transplant—overruling the urgent appeals of an array of doctors and nurses—is indicative of the failures of the new health care plan sponsored by Arnold Schwarzenegger and [Assembly Speaker] Fabian Núñez” the release said. “That plan, which is actively supported by CIGNA, requires every single Californian to purchase insurance products from companies like CIGNA, but does not address the problem of denial of care evident in this situation.”

  As soon as I heard about the news release—from a reporter who called asking for CIGNA’s reaction to it—a colleague and I immediately began alerting the company’s top executives. The first person I forwarded the release to, of course, was my boss, Carol Ann Petren.

  When Petren responded to my e-mail by asking if I would have the draft of a policy paper on her desk first thing the next morning, I knew she hadn’t grasped the significance of what was happening. I immediately ran up the stairs from my office on the sixteenth floor to hers on the seventeenth and interrupted a meeting she was in.

  After I stressed what it meant that the national media was covering a protest at our headquarters in California, she realized she had better brief our CEO, Ed Hanway, whose office was on the other end of the hall from hers. She called him herself and then asked her assistant to track down two other executives: David Cordani, then president of CIGNA HealthCare, and Dr. Jeffrey Kang, the company’s chief medical officer. Hanway was in Petren’s office in a matter of minutes. Cordani and Kang, who worked in Bloomfield, Connecticut, where CIGNA’s health care operations were based, joined us by phone.

  Kang, whom CIGNA’s transplant medical director had briefed a few days earlier, explained the reasoning behind the denial and said that based on what the medical director had told him about Nataline’s worsening condition, he supported the decision not to cover the transplant. He added, however, that he had ordered an expedited external review of the case, and the results were expected the next day.

  Waiting until the next day to hear from the reviewers was completely out of the question. TV crews were already setting up in front of CIGNA’s Glendale offices, so our discussion quickly turned to the PR damage that Nataline’s story would do to the company. As I always did in situations like this, I explained the PR consequences—the likely damage to the company’s reputation—if we didn’t relent and agree to cover the transplant. I noted that it would be different if the patient were an older person. Reporters probably would not have found the story at all compelling if the patient had been a forty-five-year-old man. The fact that the patient was a sweet-looking seventeen-year-old girl, whose smiling face had been seen by thousands of TV viewers in Southern California, made the story irresistible to the media. There was no way the company would be perceived as anything other than a cold, heartless corporation if we didn’t give a teenage girl a fighting chance to live, even if the odds weren’t that good that she’d survive.

  Because the scheduled protest was attracting so much media attention, it was clear we would need outside public relations support to help deal with what could become the biggest PR crisis in company history. The first person Petren mentioned was Larry Rand, highly regarded in the corporate world for his crisis communications skills. Rand was one of the founders of Kekst and Company, a New York firm that specializes in investor relations and financial PR for publicly traded companies. CIGNA had Kekst on retainer so that Rand and his staff would be available whenever we needed them.

  Hanway agreed that we needed them now.

  Rand was in a meeting when Petren called him. His assistant said she’d have him call her back later.

  “No, I need him right now,” Petren told her. “It’s urgent. Tell him Ed [Hanway] is here with me.”

  Rand was on the phone in minutes, and when Petren told him about the protest, he didn’t need to hear anything else.

  “Look, Carol, you have to make this go away. Approve the transplant—now.”

  Although I had given the same advice, Hanway and Petren needed to hear it from an outside expert. If Nataline died, CIGNA would be blamed for her death, and the resulting publicity would be so bad that the company could lose customers. I added that it would just be a matter of time before one of the presidential candidates seized on the story—possibly elevating it to a disaster for the entire industry.

  The group quickly agreed that damage control was of paramount importance. Cordani, who as president of CIGNA’s health care division had the most to lose, made the decision: CIGNA itself would pay for the transplant, using its own money rather than asking Mercedes-Benz to cover it. I was relieved. I was certain that even though the media would report that CIGNA had caved to pressure, the bad publicity would be over soon and people would forget the case or at least forget that CIGNA was the insurance company involved. There would be no long-term reputational damage.

  I was just as relieved, though, for Nataline’s family. This harrowing and frightening episode in their lives just might have a happy ending. I imagined how joyous and hopeful my wife and I would be to hear from our insurance company—which would be CIGNA—that a procedure that might save Emily’s life had been given “clearance.”

  I sent a quick e-mail to AHIP’s PR staff to let them know that CIGNA would soon notify the family that it would cover the transplant, because they, too, were being inundated with calls. Before we could say anything about it to the media, however, someone had to get word to Nataline’s family and doctors. Kang said he would make sure that the transplant case manager reached out to them right away. The other thing that needed doing right away was crafting the words to explain why we had changed our minds. We’d have to explain it in a way that didn’t look like we were caving in—or setting a precedent tha
t could nip us in the future.

  It was my job to figure out how to say that CIGNA was now agreeing to approve a transplant even though we still believed we’d been right to deny it in the first place—and that our change of heart had nothing to do with the bad publicity.

  RIGHT DECISION, BUT A LITTLE TOO LATE

  As I ran downstairs to start writing, I knew my staff would be happy to hear about the reversal. We had all gotten caught up in the story emotionally and were hoping that Nataline would be able to get the transplant and that it wouldn’t be too late. Although the prevailing belief was that Nataline’s chances of survival were slim—even if she got the transplant—I didn’t want to believe it. I still imagined a happy outcome, with Nataline walking out of the hospital in a few weeks with her mom and dad and brother.

  I also knew that no one would really believe that CIGNA had changed its mind solely out of empathy for Nataline and her family. But I was willing to spin it that way.

  I was under the gun to write the statement and get it to Petren and the others for their review, but I decided to quickly check my e-mail first to see if there were any new developments or media inquiries. I couldn’t believe what I saw. E-mails were literally pouring in—at least five hundred more than when I had left for Petren’s office. A few were from the media, but most were from people all over the country who’d heard about CIGNA’s refusal and were writing to express their anger and outrage. I read a few and then alerted security because some were wishing harm to my family and me. I had to ignore most of them, for the time being anyway, because I had to begin writing what CIGNA as a company would say to the Sarkisyans and the world. About an hour before the start of the protest in California, I finished a draft of what would be the core of both our media statement and the letter to Nataline’s father.