NATALINE SARKISYAN, THE RATIONAL HEALTHCARE ECONOMIST, AND THE ABANDONED AND MALIGNANT HEARTS OF PLAINTIFF’S LAWYERS.

Wow, with a title like that, what’s the megillah?

Nataline Sarkisyan was a 17-year old girl suffering from leukemia. She had been seriously ill for some time and was given a bone-marrow transplant. However, her liver failed.

Transplant specialists at UCLA recommended a liver transplant, a highly controversial, experimental, and, according to transplant experts, a very high-risk procedure and futile procedure.

CIGNA, on behalf of the employer self-funded plan for the Sarkisyan family, denied the procedure on the basis that it would be an “experimental procedure” for a patient this ill. All health plans exclude coverage for procedures that are “experimental, investigational, or unproven.”

The UCLA doctors said that the procedure would give Nataline a 65% chance of living six months. Some transplant experts were skeptical of the claim that the procedure would give the girl even a 65% chance of another six months, as data to support this estimate was not provided by the UCLA surgeons.

One transplant expert described the procedure, in hypothetical terms, as futile.

Dr. Stuart Knechtle, who heads the liver transplant program at the University of Wisconsin at Madison, was more definite: “Transplantation is not an option for leukemia patients because the immunosuppressant drugs [that the patient needs to take so that he or she does not reject the organ] tend to increase the risk and growth of any tumors," Knechtle declared.

“The procedure would be futile," he added, although the Associated Press notes that he was not commenting specifically on Nataline’s case.

The procedure required a $75,000 down payment to UCLA, and would likely run into the several hundreds of thousands of dollars. CIGNA, who was the administrator of the employer plan (and would not have to pay the cost the transplant), denied the treatment on behalf of the employer. As the administrator of the employer plan, CIGNA made the initial decisions on treatments. But it is up to the employer itself to make the final decision. At anytime, the employer could ignore CIGNA’s recommendation and approve the treatment.

After tremendous, and uninformed media and public pressure, CIGNA, on behalf of the employer, relented and said it would approve the virtually futile transplant. However, Nataline died about the time that the transplant was approved. At the time Nataline was on life support, and the decision was made by her family to take her off life support. And according to Nataline’s mother, Nataline had been in vegetative state for weeks. Arguably, there was no “Nataline” available for futile life-prolonging procedures.

Predictably, the family hired a looting plaintiff’s lawyer and they have gone as disingenuously far as to ask the Los Angeles County Prosecutor to file manslaughter charges against CIGNA.

HERE COMES THE ECONOMIC ANALYSIS.

A commonly used measure of the economic/clinical value of treatment is the QALY. The Author addressed the QALY in some posts from July of 2006. QALY stands for Quality Adjusted Life Years. QALY is a formula for measuring the long-term effectiveness of a healthcare treatment or intervention. QALYs are often combined with a cost factor to assess and compare the relative value of a treatment or intervention.

Below is a quote from the post WHAT’S IT WORTH TO HEAL THE SICK? OR TO PROVIDE PREVENTIVE CARE? OR TO DO NOTHING?

QALYs can also be less than one, and many interventions yield less than perfect health. Death is assigned a factor of 0. Some health states are considered worse than death (consider Terry Schaivo). Below is a graph of QALY health state valuations using the EQ-5D weighting system:

Health state Description Valuation

11111 No problems 1.000

11221 No problems walking about; no problems with self-care; some problems with performing usual activities; some pain or discomfort; not anxious or depressed 0.760

22222 Some problems walking about; some problems washing or dressing self;
some problems with performing usual activities; moderate pain or discomfort;
moderately anxious or depressed 0.516

12321 No problems walking about; some problems washing or dressing self; unable to perform usual activities; some pain or discomfort; not anxious or depressed 0.329

21123 Some problems walking about; no problems with self-care; no problems
with performing usual activities; moderate pain or discomfort; extremely
anxious or depressed 0.222

23322 Some problems walking about, unable to wash or dress self, unable to perform usual activities, moderate pain or discomfort, moderately anxious or depressed 0.079

33332 Confined to bed; unable to wash or dress self; unable to perform usual
activities; extreme pain or discomfort; moderately anxious or depressed
-0.429

Note that the last condition yields a QALY of less than 0. Also remember that this scale is much generalized. This health state scale was taken from “What is a QALY”, published by Hayward Medical Communications.

QALYs must also be coupled with an economics factor. Currently, it is generally considered “cost-effective” is one QALY, or adjusted QALY, costs $50,000 or less. For example, if a surgery or treatment will cost $90,000 and allow the patient to live another three years, then the treatment is seen as cost effective:

$90,000 / 3 QALYS = $30,000/QALY.

However, if the treatment costs $400,000 and will yield six months of life at the condition described at 23322 of the EQ-5D Weighting System, above, then the cost-effectiveness of the results look far different:

$400,000 provides (.5(six months of life) * .079 (23322)) = .0395 QALYs

The treatment would have to provide 8 QALYs to be cost-effective ($400,000 / 8 QALYS = $50,000).

One should also consider the fact that the prognosis post-surgery for Nataline was extremely poor and she would be in extreme pain and discomfort. So it should be considered that Nataline’s post-surgical six month life would more likely be at a state approaching 33332, or a negative QALY. At this stage, any treatment, save for palliative care, would be economically unjustified.

WHAT DOES ALL OF THIS MEAN?

Many things emerge from this tragic case, but the Author will address only a two. For a discussion of many of the implicated issues, see the other two posts.

1. As patients approach the end of their lives, they must argue against the application of futile efforts. With a young patient, futile treatments are demanded as a matter of right. There should be no issue as regards to futility. If a treatment is futile, it is futile at any stage in life.

2. Under a single-payor, government managed healthcare system, the government would be in the position of saying “no” to such treatment. Uninformed individuals, misguided activists and thieves with law licenses malign an employer and its health-benefits administrator when they deny such futile treatment. But government administered programs such as Medicaid and Medicare have clear treatment guidelines and often lag private insurers in approving new and costly treatments. Medicare and Medicaid routinely deny treatments based upon the “experimental, investigational or unproven” exclusion.

This is also the experience with national systems from Europe and Canada. These systems routinely deny such futile treatments. Would things be any different if the government said “no” as opposed to a private insurer?

Admittedly, this is a tragic and hard case. But the issues cannot be avoided, especially because the truth of the case has been ignored by the mainstream media and misrepresented by self-interested advocates.

AS READERS ARE FREQUENTLY REMINDED, MOST LESSONS ARE HARD LESSONS IN THE DESERT OF THE REAL. THAT IS WHY YOU ARE READING THE DESERT OF THE REAL AND NOT WATCHING “THE VIEW”.