Featuring Wendell Potter, Dr. Barbara Goff, Dr. Anthony Cardillo and Rachel Madley: How does America’s corporate healthcare system delay and deny care to save money and increase profits? Host Brenda Gazzar explores how such denials impact patients and their doctors. How would things be different if America had Medicare for All? Featuring Wendell Potter, co-founder of Business for Medicare for All and former Corporate Communications Director with CIGNA, Dr. Barbara Goff, a board-certified gynecologic oncologist, Dr. Anthony Cardillo, an Emergency Physician and CEO of Mend Health, and Rachel Madley, a PhD candidate at Columbia University Medical Center who is a patient with a chronic illness.
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—– TRANSCRIPT —–
(Opening MUSIC – “Talk Back” 5 seconds, fade down)
Welcome to Code WACK!, your podcast on the state of America’s crumbling healthcare system and how Medicare for All could help. I’m your host Brenda Gazzar.
Today, we’ll hear about patients who have fallen victim — sometimes with tragic consequences — to our flawed healthcare system. Enjoy the story.
(MUSIC – “Talk Back” 5 seconds, fade down )
—– FEATURE —–
How should we measure the quality of a healthcare system? One critical question is whether it meets the needs of society’s most vulnerable. In the U.S., it’s not uncommon for chronically ill children, young adults and their families to fight with private health insurers to get life-saving treatment their doctors prescribe. Join us as we learn more about the challenges that these and other patients face seeking care in one of the richest countries on Earth.
WENDELL POTTER
Wendell Potter was head of corporate communications for the health insurer Cigna when he first heard of teen Nataline Sarkisyan. It was early December of 2007.
“It came to my attention from a reporter in Los Angeles who was calling because she had heard that Cigna had denied a request for covering a liver transplant for Nataline Sarkisyan…Typically these things never reach the media; this one did.”
When Nataline became violently ill following aggressive treatment for leukemia, her doctor determined that a new liver would likely save her life. Although a perfect match arrived at a Los Angeles hospital, staff informed the family they could not do the procedure because Cigna would not pay for it.
Potter looked into the issue internally but offered the reporter a standard, unhelpful response.
“I’m sorry we can’t talk about any of our members because of federal privacy laws, and I can’t even acknowledge that she’s enrolled in a Cigna plan. That usually did the trick.”
But that wasn’t the case with Nataline and her family.
“They were very savvy, they were able to generate a lot of interest in the media in Los Angeles, and later far beyond L.A. to raise awareness of this denial.”
The family organized a protest with the California Nurses Association at Cigna’s Glendale office that attracted hundreds of people.
Audio clip of chanting: “No more denials, no more denials, health care for all”
Potter was watching the protest on CNN at the time.
“And this really did become a PR problem for Cigna. Ultimately, the executives of the company decided, ‘let’s try to make this go away, let’s make an exception here and cover this request.”
Audio clip: Screams, cheers
“But the problem was that so much time had passed since the original request had been made for coverage of the transplant that she got sicker and some of her other organs began to shut down and she died just a few hours later.”
Nataline was only 17 years old.
So why did Cigna initially deny the liver transplant? The procedure was even listed as a covered benefit on the Sarkisyan insurance plan. However, a medical director from Cigna in Pittsburgh decided — against the assessment of her treating physician — that the procedure wasn’t medically necessary.
Potter: “Obviously, he had never laid eyes on Nataline. All he saw was just the request for coverage.
What the family wasn’t aware of and what most Americans aren’t aware of even if it is written in your policy, if it’s in black and white that transplants are covered, that doesn’t mean you’re going to get it when you need one.
The reality is even within Cigna if that case had been assigned to a different medical director, Nataline might be alive today. It’s a very subjective decision. And why do you want someone who works for a corporation to make those decisions?
Potter said that there’s pressure for these doctors and nurses who work for insurance companies to help the companies make their profit.
“You’re basically evaluated on that metric. What did you do to help the company make money this quarter and this year? …If they have not helped the company make money, they’ll be questioned why so they know they have to do what they need to do.”
Potter chose to leave his job with Cigna shortly after Nataline’s death. He said he just couldn’t take another high-profile case. He now leads the nonprofit Business for Medicare for All, which makes the business and economic case to move to a single-payer health insurance system.
Denial of lifesaving treatment is not the only challenge patients face under our current healthcare system. The denial of prescribed medicines is also a common problem.
DR. BARBARA GOFF
Dr. Barbara Goff is a professor and chair of obstetrics and gynecology at the University of Washington School of Medicine — and a practicing gynecologic oncologist.
“We really try to advocate for our patients for them to get the cutting edge drugs that are most likely to provide success for these patients and we’re constantly seeing denials from insurance companies.”
And in the meantime, patients are dying. She cited a case in which one of her patients had advanced ovarian cancer. One of the most effective regimens was a drug with a high price tag that Dr. Goff wanted her patient to take.
“But the insurance company said we need to use the less expensive drug first, rather than using the drugs that have this targeted therapy, and the patient died as we were waiting to finally get approval for the more effective regimen.”
This happened over the span of months, she said. Might the patient have lived if the more effective drug had been covered by her insurance?
“I don’t know if it would have made a difference but I felt horrible that the patient didn’t get the right to try… As a board-certified gynecologic oncologist who has been treating patients for 28 years, you know, some insurance executive thinks that they know better than me and I just think that’s really frustrating.”
RACHEL MADLEY
Patients face other challenges, too. Rachel Madley, a PhD candidate at Columbia University Medical Center, was diagnosed with Type-1 diabetes at the age of 14. By the time she got the diagnosis and went to the hospital, doctors realized that she was dangerously close to going into diabetic ketoacidosis, a serious complication that happens when the body doesn’t produce enough insulin.
Madley: “The doctors estimated that my body only would have been able to continue running about one more day before I did slip into a coma. I was incredibly lucky that didn’t happen. That happens to a lot of diabetics right before they’re diagnosed, and also due to a lack of insulin, let’s say if people can’t afford their insulin, or their pharmacies closed or one of their vials breaks and they can’t get a new one.”
Madley, today a Medicare-for-All activist, had another close call as a young adult that underscores the dangers patients face under our flawed healthcare system.
While an undergrad at the University of Michigan, her insurance company inexplicably denied coverage for her life-saving insulin. She had been going back and forth with the insurance company for weeks when she completely ran out. She went to the pharmacy to try again but was charged several hundred dollars for a month’s supply — something she simply could not afford.
“And so I called the insurance company and it happened to be Good Friday, right before Easter, and unfortunately, and unbeknownst to me, the insurance company was closed for good Friday and so now I had a 3-day weekend ahead of me, where no one was available at the insurance company to speak to and I was out of insulin.
So the pharmacist saw me on the phone trying to talk to the insurance company, I called my mom. I told her what happened. We were trying to figure out what to do. And he very kindly gave me a vial of insulin to take that weekend, so that I didn’t have to go without insulin…That day the pharmacist saved my life.”
Largely due to the family’s financial circumstances, Madley had to switch frequently from one insurance plan to another. There was even a time that she went without health insurance.
“It made it very difficult to get first of all any care at all, so I was paying hundreds of dollars just for one vial of insulin which I need constantly to stay alive so that was really challenging.”
“But the switching between health insurance plans really deteriorated my care because each plan within each company has a specific list of drugs that they call “preferred” and when I would switch, sometimes I would have to switch between brands of insulin and although they are theoretically the same, they affect your blood sugar and your body differently so each time you switch you have to adjust.
So what does this say about our current healthcare system?
“So in every case that I have struggled to get insulin, or supplies, or my parents have gone into debt, it has been because insurance companies and pharmaceutical companies are most concerned about their profits and how much money they can make from your medication, from your insurance premium. And it’s never really about patient care.
To me, the solution is eliminating private health insurance companies that’s one part of it, and switching to a single-payer, improved and expanded Medicare-for-All healthcare system.”
Many physicians, too, agree that the status quo is unacceptable.
DR. ANTHONY CARDILLO
I recently met Dr. Anthony Cardillo, president and CEO of Mend Health, at the Mend Urgent Care clinic in suburban Los Angeles. He’s also an emergency room doctor.
What are some of the issues that most concern you regarding patient care?
“There’s tremendous disparity in the health care people get for the same diagnosis. And that’s the big issue here. You will get different care depending on which health insurance is covering that care and that should be outlawed.
As a physician, it’s very hard to have a girl sitting there who is a 12-year-old with abdominal pain and who is most likely having appendicitis, now I have to route her to all these places get her to the ER, it’s a waste of time to get care, and another girl walked in whose 12-years-old with identical complaint but had a different insurance in her parents wallet, I could have gone down the block and had a cat scan in 20 minutes in an outpatient center.
I just spent the day in the ER today and people that have HMO plans I’m being asked to discharge home because the hospital stay is going to be too expensive and so they discharge the patient home. We’ll get home health, we’ll get a home nurse come to the house, we’ll do an outpatient cardiac workup. They can’t afford to do it at the hospital…These are social injustices that are happening every single day, in every single hospital throughout America.
Do you have a specific anecdote that illustrates how wack our healthcare system is?
“I have hundreds and hundreds of patients that I’ve seen but one most recent was a lady who had metastatic breast cancer, she was part of a managed Medi-Cal plan. She could not get in because there wasn’t enough room to see the primary (care) doctor. There were multiple roadblocks to get the mammogram approved. Finally, she had a screening mammogram, which showed a mass. Then it took another 3 months to see a specialist. By the time she got through the process, like 9 months later, she had metastatic breast cancer. With a PPO plan, she would have been seen immediately and this happens every single day cause it’s delayed care.”
So what do you think is the solution to all these problems?
“There has to be extra financial resources to help us take care of all these patients.
Single-payer structured properly would allow that to happen because now every doctor in California would be willing to see every single patient. The wait times would go down dramatically, a radiology center wouldn’t have to worry about pre-authorizations, wouldn’t have to worry about whether or not they take that insurance or not.
WENDELL POTTER
Wendell Potter, the former Cigna executive, says America has the most unfair way of rationing health care on the planet.
“We ration care on the ability to pay.”
Medicare for All would cover everybody — including for dental, hearing and long-term care, he said.
“We have about 30 million people once again in this country who don’t have insurance and many million more than that are underinsured, meaning they are on high deductible plans and don’t have enough money to pay the deductibles to get the care that they need so they go without care.”
While the Affordable Care Act did make some improvements, it still fell short.
“And the reason it did is because it left intact this employer-based system and it left intact the role of private insurance companies to call the shots in our healthcare system to get squarely between a patient and his or her doctor. We’ve got to get rid of that, and the sooner the better, and Medicare for All would do that.”
“There are many, many Natalines out there that you’ve never heard about who’ve lost their lives because of an insurance company bureaucrat saying no.”
(MUSIC – “Talk Back” 10 seconds, fade down)
Outro
Well that’s it for today’s Code WACK!, a podcast by HEAL California. If you like what you’ve heard, please share, follow, and like us on Twitter and Facebook. Subscribe to our email updates at HEAL dash C-A dot org. This is a project of the California OneCare Education Fund. And I’m Brenda Gazzar.
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HEAL California is an independent news and information hub focused on the California Medicare for All movement. We feature non-partisan news, views, podcasts and videos that highlight the continuing failures of our broken healthcare system and elevate the voices of advocates and organizations fighting for change.
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Insurance is not the only problem. We had to go to the ceo of Ochsner Hospital and beg for treatment for our son who was bleeding severely from ibd. The GI Dept was denying him treatment because he had shouted at a phlebotamist at a Remicade infusion. On medicaid he had no where else to go. But they denied him treatment for days until the ceo told them they had to provide service. He became much sicker in the process and almost lost his colon.
Thank you for listening to our Code WACK podcast episode on patient care and for sharing your ordeal. I’m so sorry that you and your son went through all that. Can we ask how old your son was when this happened? Would you be willing to share your story at some point with us for a future podcast episode?