Deadly Spin

by Wendell Potter

  The letter was the first priority, and after numerous edits it was ready to go. “Dear Mr. Sarkisyan,” it began. “We received an appeal request on Dec. 17, 2007. We understand you are appealing the medical necessity denial for a liver transplant for your daughter, Nataline. After reviewing the information submitted with your appeal request and the terms of your benefit plan, I am pleased to let you know that on Dec. 20, 2007, CIGNA HealthCare has decided to make an exception in this rare and unusual case, and we will provide coverage should Nataline’s health care providers determine to proceed with the requested liver transplant. We are making this decision on a one-time basis, based on the unusual circumstances of this matter, although the treatment, if provided, would be outside the scope of the plan’s coverage and despite lack of medical evidence regarding the effectiveness of such treatment.”

  I also had my media statement ready to blast to the media as soon as the letter was hand delivered to the Sarkisyan home.

  With just ten minutes to go before the protest was to begin, I still didn’t have confirmation that the letter had been delivered, so I started calling around to find out what was going on. There was a hitch no one had anticipated: The Sarkisyans were not at home, and no one knew where to find them.

  It occurred to me that they probably were on their way to the protest. So I turned on the TV in my office, and sure enough, CNN was broadcasting live from the front of CIGNA’s Glendale offices, and I could see a woman in the crowd who I assumed was Nataline’s mother amid what looked like scores of nurses carrying signs with Nataline’s picture and the message CALL CIGNA TODAY. The crowd was chanting, “No more denials, no more denials, health care for all now.”

  I called CIGNA’s top lawyer in California, Bill Jameson, and told him he would have to send someone right away to tell the Sarkisyans that CIGNA would pay for the transplant. Hilda had already been interviewed on camera and clearly didn’t know.

  A few minutes later, I saw someone whisper in her ear. I could tell she was getting the good news. “CIGNA just approved!” she screamed.

  The campaign had worked. CIGNA had been pressured into reversing the denial. Grigor Sarkisyan gave his wife a big hug. They looked so relieved and so happy.

  The crowd cheered. Tears were streaming down the faces of many of the protesters.

  I was just as happy as they were—and just as relieved.

  Within an hour, CNA issued a news release with the headline “CIGNA Capitulates to Patient Revolt. Following Massive Protest, Insurer Authorizes Transplant for 17-year-old Nataline Sarkisyan. CNA-Sponsored Protest Sparks Flood of Calls from Across U.S.”

  “CIGNA had to back down in the face of a mobilized network of patient advocates and health care activists who would not take no for an answer,” the release quoted CNA executive director Rose Ann DeMoro as saying.

  I would never acknowledge it publicly, but DeMoro, of course, was right. CIGNA had capitulated. My job now was to spin the reversal in a convoluted way that would make people think the media attention, the protest, the calls, and the e-mails had nothing to do with it.

  “Our hearts go out to Nataline and her family as they endure this terrible ordeal,” the media statement began. Then there was this fifty-nine-word whopper of a sentence that only a lawyer could love: “Based on the unique circumstances of this situation, and although it is outside the scope of the plan’s coverage and despite the lack of medical evidence regarding the effectiveness of such treatment, CIGNA HealthCare has decided to make an exception in this rare and unusual case and we will provide coverage should she proceed with the requested liver transplant.”

  The statement ended with this: “Our thoughts and prayers are with Nataline and her family at this difficult time.”

  That last part was true, at least for me. My thoughts and prayers actually were with Nataline and her family, as were those of many CIGNA employees. I felt a little queasy about writing it, though, because I knew it was a PR contrivance—and one we used whenever we had to issue a statement in such circumstances. PR people know that in situations like this one, it is important to convey how sympathetic and caring we are.

  I went home late, exhausted, but knowing that the stress of my day was nothing compared to what the Sarkisyans had gone through. I was happy for them and hoped they would all get much-needed rest before Nataline’s transplant.

  But a few minutes after ten P.M., my phone rang at home. There would be no need for CIGNA to cover the transplant after all. Nataline had just died.

  A LIFE SLIPS AWAY

  Hilda Sarkisyan had no idea her daughter was so close to death when talking to the reporters in front of CIGNA’s offices. “I told the media my daughter was going to be fine,” she said. “She’ll be getting the transplant.”

  However, when she arrived at the hospital after the protest, many friends and family members were already there. Her husband, in fact, had slipped away from the protest and returned to the hospital alone after his sister had called to tell him that Nataline’s condition had taken a turn for the worse. Hilda found out later that many of her relatives and friends had learned before she did that Nataline was not going to recover.

  “I was shocked to see so many people there,” she said. “Even the archbishop was there. One of the main leaders of the Armenian community came, and the next thing you know, my husband, my uncle and my aunt, everybody was staring at me. Then my husband said, ‘Hilda, I love you.’

  “ ‘Why did you say that?’ I thought. We’re not like that. We love each other, but we don’t say that in public.

  “I said, ‘Okaaay.’

  “ ‘Hilda,’ he said, ‘our daughter just passed away.’

  “They had to put me in a wheelchair.”

  With tears streaming down her face, she searched in her purse for a notepad. “I just began to write,” she said. “I had done everything I could to save Nataline, but I knew my work was not over. I felt actually that my real work was just beginning. I promised Nataline as I said good-bye to her that I was going to make sure people understood that what happened to her, what happened to our family, could happen to them, too.”

  THE SPIN BEGINS

  When I heard that Nataline had died, I knew that my real work had just begun, too. My top priority—the first responsibility listed in my job description—was to “protect, defend and enhance” the company’s reputation. The size of my raise and bonus depended on just how well I managed to do that, and I knew I would play a central role in a weeks-long, all-out damage-control campaign. I would have to convince the media and the public—in a very nuanced and subtle way—that CIGNA, despite its reversal, had been right in denying coverage for the transplant in the first place, that it had, in fact, had a responsibility to its customers to refuse to pay for it.

  It turned out to be both my biggest and my last attempt to influence public opinion on behalf of an industry I had served for nearly two decades.

  My heart wasn’t in it. On reflection, I was actually grieving, although I didn’t realize it at the time. What I did know was that I didn’t feel up to the task of spinning. I felt, instead, burned out. But I had a job to do, and I had to do it. Whether I liked it or not, I was going to be the company’s main voice on the case, although I would enlist our chief medical officer, Kang, to talk with the media as well. One of the things I had learned years ago was that executives with an M.D. after their names were especially influential with reporters when the stories pertained to patient care. Whenever I could manage it, I would try to get CIGNA’s point of view delivered in print by a medical director, if for no other reason than to have the M.D. appear in the story—especially if it was a horror story.

  The first thing I did after I learned of Nataline’s death was brief my boss, Petren. The second thing I did was call the media-monitoring services I used and ask them to send me every story that appeared anywhere in the world, in any medium—print, broadcast, or online—as soon as possible. Third, I started writing the media statement we would b
egin using the next day.

  “Our deepest sympathies are with the Sarkisyan family as they mourn the death of Nataline,” I wrote. “All of us at CIGNA send our thoughts and prayers to those who were touched by Nataline’s life.” I knew I had to start it that way, and it was heartfelt, but it nevertheless seemed like I was writing those sentiments only because it was a PR necessity.

  I went on to note, in awkward prose, that CIGNA had agreed to cover the transplant “even though there was no medical evidence regarding the effectiveness of a liver transplant in this rare case, and no coverage for this procedure under the health plan chosen by the employer who provided health benefits to the Sarkisyan family.” I added that CIGNA had a responsibility to its customers “to make medically appropriate decisions based on scientific and clinical evidence.”

  Petren and others who reviewed the statement made edits for legal reasons that I thought made the language even more awkward, but there was nothing unusual about that. Lawyers always had the last word when litigation was possible or anticipated.

  The news coverage before Nataline’s death, significant as it was, paled in comparison to the avalanche of media reports and blog posts that began almost immediately after. The first batch retrieved by the monitoring services went on for pages. I only had to read the headlines to grasp how damaging the publicity was going to be.

  The one bit of good news for CIGNA was that the company was not mentioned by name in most of the headlines. People had to read or listen further to know or remember that CIGNA was the company. This was not much of a silver lining, because most of the broadcast stories did include clips from the protest in front of CIGNA’s Glendale building—and the company’s turquoise “tree of life” logo, with the tagline “Business of Caring” below it, appeared in many of the news reports.

  My staff and I were quickly overwhelmed. It was not possible for us to talk to every reporter who called seeking comment or an on-camera interview. I asked my assistant to get every reporter’s e-mail address and then send them our statement with a note telling them they could attribute it to me as the company’s spokesman. I returned a few calls, but only to reporters at the major newspapers and networks. We had to have help.

  Petren had been impressed with the way that PR firm APCO had earlier worked behind the scenes on behalf of the industry to discredit Michael Moore’s Sicko. After a brief conversation with Robert Schooling, the APCO executive who had led the Sicko work, she hired the firm. In addition to Schooling, APCO would assign Myron Marlin, senior vice president and senior strategist, to the account. A lawyer as well as a PR guy, Marlin had been director of public affairs at the Department of Justice during the Clinton administration. Schooling and Marlin would become active participants in the twice-daily “California case” strategy sessions and conference calls led by Nicole Jones, our corporate secretary.

  Jones’s “lead team,” as she called the group, also included Hanway, Cordani, Kang, Brian Benjet (who headed litigation for CIGNA), G. William Hoagland (the company’s Washington-based vice president of government affairs, who had been a top aide to Senate majority leader Bill Frist), and Larry Rand and Lissa Perlman, both of Kekst. Karen Ignagni, president of AHIP, also called in occasionally, as did her lieutenant, Mike Tuffin, who led strategic communications for the trade group.

  Benjet was a member of the lead team because the Sarkisyans had hired Mark Geragos, often referred to as the “lawyer to the stars” (Michael Jackson was among his famous clients), to represent them. Geragos had also long been active in the Armenian community in Los Angeles. Hilda Sarkisyan said that she and her husband had retained him initially in their efforts to get CIGNA to pay for the transplant; the day after Nataline died, he held a press conference to announce that he would be filing a lawsuit against CIGNA.

  “My reading of the statute is clear that this corporation had the mental state that they consciously disregarded her life,” Geragos said at the press conference. In addition to filing his own lawsuit, he said, he planned to ask the U.S. attorney in Los Angeles, Thomas O’Brien, to press murder or manslaughter charges against the company that “maliciously killed” Nataline because it didn’t want to bear the expense of her transplant and aftercare.

  After those comments made headlines, Benjet hired Debra Yang, who was O’Brien’s predecessor as U.S. attorney until she resigned in 2006 to join a big international law firm. The lead team also started a “Geragos watch” to monitor his actions and comments. As part of that watch, Yang arranged to have someone attend Nataline’s funeral on December 28 and report back if the company was mentioned in any way during the service.

  Schooling and Marlin’s responsibilities were to help create a detailed communications plan that would encompass the same tactics that APCO had used in its behind-the-scenes campaign against Sicko. The plan was ready for review by the lead team on December 30 and, like the Sicko strategy, relied heavily on the firm’s ability to place stories with reporters, editors, and producers it had good relationships with and to get “third parties” to convey CIGNA’s messages.

  The main objective was to try to drive reporting on the case to the broader issue of tough decisions that have to be made about the allocation of scarce organs and whether someone in Nataline’s condition would have been approved for a transplant in any other health care system around the world. The point was to disabuse the media, politicians, and the public of the notion that Nataline would have gotten the transplant if she had lived in Canada or France or England or any other developed country.

  APCO planned an aggressive outreach to reporters and pundits likely to be most receptive to such “big picture” stories and to be sympathetic to CIGNA’s point of view. APCO would also draft and work to place letters to the editor and op-ed pieces “to set the record straight” if a newspaper carried a negative story or editorial about the case. Knowing that the industry was worried that advocates of health care reform would seize on the case as a reason why the American health care system needed to be drastically overhauled, APCO would use the op-eds as vehicles to also argue that a government-run system would not keep such cases from happening in the future, and to suggest that a more useful role for government would be to develop a national policy on coverage for “experimental” treatments.

  The pundits APCO proposed to reach included some of the most famous TV health care reporters and commentators, and the list of third-party advocates was a who’s who of reliable insurance industry allies, including many of the same people APCO had enlisted earlier to help in its Sicko-bashing campaign. All were associated with conservative think tanks, big-business organizations, or legal-reform groups that the health insurance industry had reached out to many times in the past for help disseminating messages that could not be traced to AHIP or any insurer. And in anticipation that Geragos would continue generating stories about his lawsuits, APCO had a second list of pundits to argue that America was plagued with “frivolous lawsuits” that were driving up the cost of health care.

  A third list was doctors whom APCO or CIGNA would ask to be third-party “experts” on organ transplants. They would be available to speak with reporters or to write op-eds, if necessary, that would convey the company’s point of view.

  AFTER THE TARGETS COMES THE SPIN

  The APCO plan also included a list of approved talking points and a comprehensive set of potential questions and answers that all of the spokespeople would be required to study before talking with anyone in the media.

  Two days before Schooling and Marlin laid out the communications plan to the lead team in Philadelphia, Nataline was laid to rest in California. Shortly before her burial, the Sarkisyan family led hundreds of mourners, many of them wearing pink (Nataline’s favorite color), into St. Mary’s Armenian Apostolic Church, the spiritual heart of the Los Angeles Armenian community. (Debra Yang reported to us that the people who spoke did not use the occasion to condemn CIGNA but to remember what Nataline had meant to them and to others.)

  A
fter the eulogies were delivered, Nataline was buried in a white coffin. Her heartbroken father had insisted on white. To keep her spirits up while she was in the hospital, he had promised Nataline that he would buy her a white Mustang as a graduation present. “I had to buy her a white coffin instead,” he told me two years later when I met the Sarkisyans in their home.

  APCO had predicted that a presidential candidate, probably John Edwards, would begin talking about the Sarkisyan case. They were right. Edwards even invited the Sarkisyan family to join a campaign stop in New Hampshire. Elizabeth Edwards, campaigning with her husband, introduced the family at an emotional town hall meeting in Manchester on January 6, 2008.

  “I feel empty inside,” Hilda Sarkisyan told the crowd. “But this is not only about my daughter Nataline; it’s about the whole world, every one of you. This could have happened to any of us. We have to put a stop to these people. They cannot tell us who’s going to live and who’s going to die. Right now I am here for her. We have to make a change.”

  After this appearance, however, media interest in the case began to wane. Thanks to the successful implementation of the APCO strategy, many of the stories that did appear focused more on CIGNA’s side of the story than on the Sarkisyans’. By this time, reporters writing about the case were looking for fresh angles, and the APCO team and I were pushing those angles to select media.

  Of course, I played a key role in this effort. One of my jobs was to arrange interviews for Kang with reporters with whom I had developed good relationships and who might be more inclined to write stories from CIGNA’s point of view. I scored several coups when favorable or at least balanced articles began to appear in important publications, including Forbes and the Wall Street Journal. These were especially important because they would be read by the CEOs and benefits managers of CIGNA’s corporate customers, some of whom were already calling us to get statements they could use with their employees who were enrolled in CIGNA plans.