Swiss Miss

Victor Saouma carefully shapes his sentences, at pains to be accurate. Part Lebanese, part Colombian, he holds himself with dignity. A professor of civil engineering who earned his doctorate at Cornell University and did post-doctoral work at Princeton, Saouma once thought of his employer, the University of Colorado, as a center for learning and high intellectual aspiration, a concordance of scholars bound together by mutual ideals.

That was before his wife, Rhea, became deathly ill in Switzerland and he discovered precisely what his fifteen-year relationship with the university was worth. Late last year, the Saoumas successfully settled a lawsuit against CU.

Rhea's health problems had started years earlier in Boulder, after a driver made a sudden and illegal left turn in front of her car and she slammed into him. She was badly injured -- whiplash, soft-tissue damage, neck and back pain -- and her treatment included high doses of antibiotic and anti-inflammatory drugs. But when doctors took her blood preparatory to some needed surgery, they discovered that her creatinine serum reading was dangerously high. It seemed the drugs had damaged her kidneys.

"It was the first time we heard about creatinine," says Rhea. "We didn't even know what it was. Basically, the type of disease I ended up with was renal tubular acidosis. The kidney did not filtrate anymore."

On her doctor's advice, Rhea eventually began the procedures necessary to get on the transplant list. But while she was undergoing interviews and tests, her condition radically improved. So in July 1997, the Saoumas decided -- with the encouragement of Rhea's doctor -- to finally take Victor's long-delayed sabbatical. They left for Switzerland, where Victor would teach at the Swiss Federal Institute of Technology in Lausanne and continue his research; Rhea would concentrate on caring for their two daughters, Caroline and Sophia. (Their son was attending college in Berkeley.) But by the spring of 1998, Rhea's health was declining rapidly. "I was a vegetable," she recalls. "Throwing up, retaining fluid. You know, with kidney failure you have no pain, but you're completely drained. You feel tired all the time. You get up an hour, you sleep two. You get up an hour, you sleep two. You sleep poorly at night and poorly during the day.

"By May, I was going downhill. The fluid in my body was so high that I went to the hospital with a heartbeat at 157. They couldn't get it to stop. It was pounding. At that point the doctor said, 'You're going on dialysis immediately,' and they inserted a catheter in my neck. It took them two weeks before they were able to remove the fluid."

Still, the catheter was only a temporary solution: Such catheters carry a high likelihood of clogging or infection, and infection posed a profound risk for Rhea, whose illness had been created, at least in part, by antibiotics and who was now allergic to most antibiotic medicines. A transplant represented the only permanent fix, and Rhea's Swiss doctors determined that Victor would be a suitable kidney donor. They also decided that if they performed the transplant soon, they wouldn't need to replace Rhea's catheter with a fistula, a more permanent implant for dialysis whose surgical installation can be painful and difficult and which also poses a high risk of infection.

So far, the Saoumas' insurance with CU had covered Rhea's care. That June, Victor called the university to check on coverage of an operation that would transplant one of his own healthy kidneys into his wife's ailing body. His request was backed by a letter from Dr. J.P. Wauters of the Department of Nephrology, University Hospital, Lausanne. "We herewith certify that Ms. Rhea Saouma is now suffering from advanced renal failure which requires urgent renal replacement therapy in the following week," Dr. Wauters wrote. "Failure to act on this will have fatal consequences. Furthermore, her conditions do not allow her to safely travel to the USA."

Since 1989, CU had given most employees the option of getting their insurance through the state or signing on for the university's self-insured plan; faculty members were eligible only for the latter. Under that system, CU set its own premiums and paid claims from a self-administered pool; treatment was provided by CU's Health Sciences Center. But plan participants could maintain a certain amount of freedom by signing up for a more expensive option, the Silver plan, which allowed for some treatment outside of CU. The Saoumas had opted for the Silver plan. "We always took a plan which provided us with the most possible choices," says Victor, adding that they'd never had any problems getting reimbursed for outside care.

But by 1997, enrollment in the Silver plan was dropping and its costs were rapidly rising, since enrollees willing to pay more for insurance also tended to need it more. Premiums were now $580 a month for a single employee and $1,702 for a family. "Only football players could afford it," Saouma remembers.

When CU administrators began discussing eliminating the option, however, many faculty members were furious over the possibility of losing the Silver plan and being confined to one provider -- even if it was their own health sciences center. Although it's not uncommon for a university associated with a medical school to make its own facilities an element of its benefit plan, CU's complete reliance on the health sciences center was highly unusual. While the center offers excellent care in many areas, certain kinds of specialists are unavailable there. And since many CU faculty members and staffers live in Boulder or Colorado Springs, being forced to bypass local hospitals and travel to Denver for every medical problem could represent a real hardship. A CU staffer who suffered a massive heart attack in Boulder and was rushed to Boulder Community Hospital was sharply rebuked by administrators for not having driven to Denver -- despite the fact that extra time on the road might have cost her her life. (CU's plan eventually covered her care.)

Still, by the end of the year, the Silver plan, now down to eight enrollees, was eliminated altogether. It was replaced by the Gold plan, which would be "a true HMO," Dr. John Sbarbaro, head of University Physicians Inc. at the medical center, told CU's employee newspaper. "Participants will not be able to go outside the network."

The Saoumas were on the Gold plan by the time Rhea's Swiss doctors told her she needed a transplant. When Victor called the university to ask about coverage, he was referred to Great West Life Assurance Co., which administered CU's self-insured program. While the Saoumas' plan did call for transplants to be performed exclusively at the medical center, a Great West representative told Victor it allowed for exceptions in urgent cases. Since Rhea's seemed to qualify, she would probably be able to have her transplant in Switzerland, Great West said. Victor asked to have that assurance in writing.

He never got it. Instead, the university benefits office consulted Dr. Sbarbaro, who, without consulting Rhea's Swiss nephrologist, determined that Rhea should get a fistula implanted in Switzerland, undergo dialysis there and travel back to Colorado for a transplant at the health sciences center.

In accordance with Dr. Sbarbaro's opinion, the university denied the Saoumas' request for a transplant in Switzerland. The plan would pay for travel to the U.S., for the fistula and for dialysis -- and, oddly, would also cover costs of up to $25,000 for the removal of Victor's kidney in Switzerland. "Which raised the obvious question," Victor says. "Why pay for the removal of a healthy kidney but not for putting it in the person who needs it?"

Frantic with worry, Victor Saouma did his best to plead his wife's case with CU via letters, phone calls and e-mails to administrators and medical personnel.

"Dr. Sbarbaro," he wrote in one missive, "my understanding is that it is your medical opinion that is being sought...and not a legal one. As such, I would like to hope that your recommendation is what is best for the patient rather than for the HMO which is seeking your opinion." In other e-mails, he tried to describe his wife's suffering. He pointed out that the transplant could be done sooner in Switzerland than in the United States: Between the need for added dialysis and the CU center's clogged schedule, even if the Saoumas returned, Rhea would have to wait at least another two months for a transplant.

When those appeals failed, Saouma tried cold, hard figures. "Let me try the financial argument," he said in an e-mail to Stuart Takeuchi, the university's vice president for administration. "The cost of the surgery here is estimated to be 60,000 Swiss francs, or $40,000. If you add four weeks of dialysis three times a week at about $400 a session, that would add $4,800, or a grand total of about $45,000." Meanwhile, the cost of having the transplant done in Denver -- factoring in the fistula surgery, the extra weeks of dialysis and the health sciences center's higher charge for the procedure itself (around $50,000) -- would come to well over $63,000.

In response, CU sought the opinion of Dr. Stephen Gorshow, Great West Life's medical director, who concurred with Sbarbaro's opinion that Rhea Saouma could return safely to the United States for transplant surgery. "I cannot find reasons to substitute my administrative judgment for the judgments made by competent medical authorities," Takeuchi wrote Victor.

Time was running out. While the Swiss doctors were pressing for a decision, CU was taking days, sometimes weeks, to answer even routine queries about ancillary costs. Finally, the Saoumas borrowed money to cover the cost of the operation, and the transplant was performed in Switzerland early in September -- three months after Victor made his initial request to the university.

Rhea's donated kidney began functioning while she was still on the operating table.

While Victor Saouma was still negotiating his wife's care with the university, an outside auditor, Leif Associates, was hired by the school to examine its health-insurance plan. Leif's results were released in early 1999, and they confirmed an earlier in-house audit that had raised serious questions about CU's system. "We don't have the resources or expertise in place at CU to operate an insurance plan," in-house auditor Jean Stewart determined. "It also is a conflicting-goals issue. We have to balance roles as insurer, employer and employee, and these roles conflict."

Leif's audit validated the widespread complaints about the program, particularly concerning inexperienced management and apparent conflicts of interest. "Instead of working to implement...mitigation elements," the audit reported, "we found management's efforts focused on minimizing the university's cost of the plans...promoting the use of internal and affiliate providers in lieu of competitive purchasing."

Even so, the plan had been losing money hand over fist. At the end of 1997, it had a deficit of about $7 million. And the university was returning only 31 percent of the interest earned on premiums to the plan, spending the rest on other internal needs.

The findings were "quite disturbing," CU professor John Daily decided, and he introduced a motion at the Boulder Faculty Association. Saying the audit revealed "an apparent conflict of interest, a looming deficit, level employer contributions, limited return on treasury earnings, inadequate resources to run the program, lack of proper accounting and audit procedures and widespread dissatisfaction," he called for an independent benefits office, to be administered "by someone with appropriate professional education and experience in management of benefit insurance plans."

By March 1999, CU's self-funded plan had a budgetary shortfall of $11.8 million, which it blamed on higher-than-anticipated use and ballooning drug costs.

That summer, the university dropped the plan altogether and began using three independent companies: Kaiser Permanente, One Health Plan of Colorado (which is offered by Great West Life Assurance Co.) and CIGNA Health Care. CU faculty now have more choice and flexibility, while retaining the option of using the health sciences center. But there are still complaints about the system, the most recent concerning the layoff of a number of nurse practitioners at local university clinics.

The deficit has shrunk to $3.8 million.

Finally back home in Boulder in early 1999, the Saoumas contacted attorney Baine Kerr. "We were asking for reimbursement plus interest from the university," says Victor. "We may not have asked for legal costs at that time. There was no suing. No."

But the university took its time responding to Kerr's inquiries, too. "I was getting sick and tired of all these ongoing discussions and getting nowhere," Victor says. Initially, he felt some hope when he discovered that Takeuchi had left the university and had been replaced by Anne Costain, a fellow faculty member from the political science department. "Maybe I was naive," Victor says now, "but I really thought that she would be in a position to take an independent, honest, rational look at the situation."

The Saoumas' first meeting with Costain seemed to go well; she listened carefully and took copious notes. But by the time formal discussions opened, not only did Costain fully support the university's decision to deny coverage of the transplant, but she was questioning Victor's judgment, suggesting he might have been too confused in Switzerland to make rational decisions about his wife's health.

"To my view, Anne Costain had two choices," Saouma says. "Option A was for her to use her heart and maybe set the tone for an improved relationship between university and faculty -- and we know how tense those relations are. Or she could become a typical CU bureaucrat, wanting to basically be a good soldier and one day become a president or provost or whatever.

"She followed option B."

He felt particularly betrayed when Costain asked to contact the dean of his department in order to determine if Victor's sabbatical had been legitimate.

With the statute of limitations approaching, the Saoumas filed suit against CU in May 2000. They were still hoping that CU would agree to cover their costs without the case actually going to court, but CU refused to budge.

"It becomes like a poker game," Victor says. "Going to court would have been expensive. We'd have had to get depositions from the Swiss doctors; we'd have needed a number of expert witnesses. But by then I was ready to confront this cost. I had the strong support and backing of my family. If it came down to this, so be it."

Although Dr. Sbarbaro was unavailable to comment to Westword, when news of the lawsuit broke last summer, he told Silver & Gold, CU's in-house newspaper: "In no way can her kidney transplant be considered or portrayed as an emergency. Her chronic kidney condition was known and being followed by the treating physician in Switzerland as early as 1997. This was clearly an elective decision by Professor Saouma."

The Saoumas' lawsuit against CU was finally served in October. Within a few weeks, an agreement was reached. The university agreed to pay the cost of the surgery, plus interest, and all of the Saoumas' legal fees. Another check was provided for an undisclosed amount.

"A big question that the case would have been oriented toward resolving is whether, and to what extent, this plan was intentionally designed to help an ailing health sciences center and, perhaps particularly, the transplant program there," says attorney Kerr. "If the lawsuit had proceeded, there would have been a lot of discovery in that area, depositions taken and internal documents sought that would have answered that question. I wonder if much of the incentive to settle was to prevent the discovery into those internal documents."

In addition to reimbursement, Victor wanted one thing more from the university: a formal letter of apology. "Where I come from, if I'm late in paying something, I usually include a cover letter with a few words of apology," he says. "I consider that the minimum they owe me."

Although CU did not admit liability in the settlement, its lawyers did draft a letter of apology, which was then passed on to Anne Costain and others involved in the case. But the letter was never sent. Victor recently repeated his request for an apology, this time directing it to Elizabeth Hoffman, CU's new president.

"This is not a commercial environment," he says. "We have to set an example in how we treat each other. There was a time when people thought of universities as places where people were treated with respect."

"It's more like a basket of crabs biting each other," adds Rhea.

In her only comment to Westword, Costain says, "We are very pleased that we were able to resolve this health-insurance issue for the Saoumas."

Rhea remains in good health, but she acknowledges that the journey she traveled through sickness and bureaucracy was intensely wearying.

As for Victor, his recovery from disillusionment could take even longer. "It affected my sense of allegiance to the university," he says of the insurance ordeal. "I came as an assistant professor after teaching at the University of Pittsburgh for two years. I was promoted here; I did my research here. I felt betrayed, cheated, disillusioned, disenchanted. It didn't have to be like that."


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