In recent months, the Clinton administration and Governor Roy Romer have unveiled plans to correct health-insurance woes. Although different in some respects, both strategies rely on a form of bidding for medical services as one means to control soaring costs.
Such bidding, on a smaller scale, already is a standard practice within health maintenance organizations and preferred provider organizations. These companies frequently negotiate exclusive contracts with hospitals and other providers in exchange for discounted prices.
Many experts expect the strategy to become much more widespread as various national and state health-care-reform plans seek ways to slash medical costs. To patients who have run into kinks with the discount-pricing-for-exclusive-contract system, however, such reforms are not necessarily good news.
Just ask the Fischers.
Cliff and Karen Fischer knew that their daughter, Michela, had a bad liver soon after she was born. But the organ didn't become a real issue until last winter, when the ten-year-old broke three bones in a matter of weeks. Although they hoped the fractures were just the result of normal childhood roughhousing, the Fischers suspected that Michela's brittle bones were a symptom of her bad liver.
The family's fears were confirmed at Children's Hospital, where Michela had been receiving checkups and treatments since 1984, when the Fischers moved to the Denver area from Dallas. After a battery of tests, the doctors said the time had come for a liver transplant. "They told us the transplant was not a matter of life and death, but rather a quality of life issue," Karen recalls. "Still, there were a lot of reasons not to wait too long."
Soon after the evaluation, Cliff, a 37-year-old engineer at Martin Marietta, called his insurer, Cigna HealthCare of Colorado, to ask how the operation would be paid for. In order to have the insurance company cover the entire cost, the Fischers were told, they would have to stay "in-network"--that is, bring their daughter to one of three "LifeSource Organ Transplant Centers" preselected by Cigna to do transplants. Their choices of centers: Los Angeles, Cleveland or Omaha.
Although the family was pleased with the Cigna representative's helpfulness, they balked at leaving behind the fine care that Michela had received at Children's. "We wanted to get the transplant done here," Karen explains. "We thought, one, it would be easier on the family; and, two, we were familiar with the doctors here. They knew Michela; they'd worked with her for her whole life. We had confidence in them."
She adds, "When you go in to see a doctor one time every three years, you don't care who your physician is. But when you're putting your kid's life in their hands, you care a lot."
Children's Hospital is a well-established, if young, transplant center. Although the hospital didn't begin doing liver operations until 1988, it has since allied itself with University Hospital and become the busiest pediatric transplant facility in the Rocky Mountain region, according to David Avrin, a hospital spokesman.
As a result, the Fischers were confident when they approached Cigna with the possibility of staying in Denver for the operation. But they quickly learned that the penalty for leaving the Cigna network was high: The insurance company would garnish a percentage of Cliff's salary each year until the out-of-network deductible of $5,300 was covered. Worse, if Michela were to suffer future complications, the deductible would have to be paid each additional year she needed treatments as a result of the operation.
Not willing to give up, the Fischers say they offered to pay the deductible for one year if Michela could have the operation done at Children's. Next, the family enlisted the help of Children's Hospital itself, which Cliff says offered to lower the cost of the operation and subsidize post-operative costs. (Doug Pascal, a financial administrator at Children's, says he can't recall details of the hospital's offers. Generally, Avrin says, "we attempted to negotiate a payment arrangement with the insurance company.") Cigna, however, would not budge.
Kathy Gies, health service manager for Cigna HealthCare of Colorado, explains that the company selects transplant sites based on various medical factors, including how many operations it performs, patient outcomes and satisfaction rates. She adds that, while Cigna currently is evaluating Children's Hospital for inclusion, the Denver hospital nevertheless remains out-of-network.
In addition to evaluating a hospital's track record, of course, Cigna also negotiates a lower price for volume business, adds Wendall Potter, Cigna's director of corporate relations in Hartford, Connecticut. He declines to discuss details of the price breaks Cigna enjoys in exchange for exclusive contracts with its LifeSource centers. But he assures that "the discount is not the overriding consideration. Our overall objective is to make sure that the quality of care is the best."
Indeed, says Karen Fischer, Cigna "made you feel like they were looking after your best interests." She adds, "They said it's not just the money." In April, the Fischers decided to trundle Michela off to Omaha.
The decision didn't seem bad at the time. Karen's parents lived in Omaha, and Cliff's family wasn't more than two hours away. Even after Michela's initial two-day visit at the end of April, during which the Nebraska team concurred with Children's recommendation for a transplant, the Fischers had no qualms about their choice.
"At that time we were very impressed," Karen recalls. "It seemed like they had their act together." In mid-May, Michela's name was added to the national list of transplant candidates.
The Fischers' lives became tied to the death of a stranger. They were issued a pager. (It tended to beep wildly in thunderstorms.) Cigna committed to pay as much as $10,000 for transportation and lodging in Omaha, and the family arranged a flight out of Centennial Airport on a private plane. "We were just waiting for something to happen," she says.
Labor Day weekend is big for people on transplant lists. Crowded roads and reckless drivers usually guarantee a big organ harvest. Last year was no exception. On September 7, at about 10 a.m., the Fischers got the call. Cliff was told that Michela had a new liver waiting in Nebraska. The whole family was on the plane by 12:30 p.m.
The operation began at about one o'clock the next morning, and lasted nearly until noon. Unfortunately, for the Fischers, it was just the beginning.
The transplant team in Omaha had prepared the family for a two-month separation from their Denver home. Michela probably would need to stay in the hospital for four weeks, they predicted, and then visit regularly as an outpatient for another month. But she began to develop complications almost immediately after the operation.
Cliff stayed with his daughter and wife as long as he could, but after five weeks he had to return to Denver and his job. He and their two boys (one recently adopted) flew back to Colorado. Karen remained behind in a motel room close to the hospital.
Within days, Michela's doctors said another operation would be necessary--immediately. "We were afraid she might not make it," Karen says. But Cliff couldn't leave for Omaha until the day after the operation. He hopped into the car with one of his sons (the other stayed with a friend) and made the ten-hour drive in nine hours.
Cliff stayed another week with Karen before having to return to Denver. "It was tough being back here again," he says.
Tired of being apart, the Fischers called Cigna in mid-October and asked if Michela could receive aftercare in Denver. The insurance company agreed--after all, only the transplant operation itself need be in Omaha, the representative said. The catch, however, was that if Michela needed a second transplant it would have to be done in Nebraska. With their daughter's condition vacillating daily--and the possibility of a second transplant very real--the family decided to continue care in Omaha.
After about eight weeks, Michela was cleared to leave the hospital. A couple of weeks later, Cliff and the boys returned to Omaha so the whole family could celebrate Thanksgiving. They stayed for one week.
After Cliff had returned to Colorado, Michela's condition deteriorated again, and she was admitted back into the hospital. Due to work pressures, Cliff couldn't immediately come to Omaha. It wasn't until a couple of days before Christmas that he was able to jump into the car with the two boys one more time, and head back to Nebraska.
The Fischers' Christmas Eve was celebrated in the hospital, with Michela on dialysis. "But at least I was there then," recalls Cliff. "So that helped."
By New Year's Eve, Michela was well enough to become an outpatient again. Nevertheless, as a result of what the Fischers felt was less-than-adequate medical care, Cliff requested a meeting with Michela's Omaha medical team.
The family had intended to return to Denver the following week. During the meeting, however, their hopes were smothered once again: The physicians recommended another surgery to repair Michela's still malfunctioning bile ducts. Exhausted, the family decided to delay the surgery and return to Denver.
"What we really were going for was a second opinion" at Children's Hospital, Karen says. Adds Cliff, "We also sort of came home to regroup." Cliff and the boys got behind the wheel for yet another ten-hour drive; Karen and Michela flew back.
Since then, the Fischers have asked Children's Hospital to assume Michela's medical care, an expense Cliff and Karen now say they would gladly pay out-of-pocket. But the Denver hospital refused, saying it would be inappropriate for it to get involved in the middle of Michela's care.
A half-year into their odyssey, the Fischers laud Cigna's representatives as responsive, and their insurance policy as thorough. "We've basically paid zilch for a liver transplant," Cliff notes. Karen adds, "We haven't even paid our $10 co-payment."
Even so, the strain of their family's being separated on and off for nearly six months--not to mention Cliff's seven weeks off work--when the operation could have been performed less than a half-hour away from their house has caused the Fischers to rethink how they'd choose between a free transplant operation hundreds of miles away, or an expensive one nearby with familiar doctors and nurses. "If there's any way we could do it all over again," Cliff says, "we'd suck it up and just pay for it."
For now, however, the family simply hopes their daughter's liver performs well enough for her to return home for good. When that day will arrive is far from clear. On February 4, the Fischers returned to Omaha so Michela, now eleven, can undergo more surgery to clear her bile ducts. The hospital has told Cliff and Karen they should expect to stay in Omaha anywhere from two weeks to two months.
