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...doctor that Hunter needed a new liver but who also recognized that insurance was very much a factor. Rubin consulted with the hospital's financial staff, which confirmed that MUSC did not have a liver-transplant contract with Hunter's carrier, Physician's Health Plan. But, Rubin was told, Duke, where he knew the liver people, did have a PHP contract. So the physician recommended that Hunter go there. Rubin placed a call to Duke hepatologist James Trotter, explaining that he had a seriously ill transplant candidate and that he understood that the insurer, PHP, had a contract with Duke...
SEPT. 3 A phone call from Joe Robbins, a Duke financial coordinator, to Jackie Brown, PHP's transplant coordinator, was the first anyone at the insurance company knew of Hunter's whereabouts. Both recognized that the patient was "out of network," but it would be weeks before anyone would sort out how it was that Hunter ended up in a hospital with no plan to pay for an operation that could cost anywhere from $80,000, if the procedure went smoothly, to perhaps $1 million, if complications arose. The precipitating error apparently took place in the back offices of MUSC...
Such confusions are the loose cog in the vastly complicated machinery of managed care, and the cause of more breakdowns--and personal agony--than anyone would care to admit. "This is reality," says Duke's Trotter. "This happens all the time...
Todd's wife Kim, along with his parents, followed him to Durham, where they all checked into a double room at the Brookwood Inn, about 500 yds. from the Duke Hospital entrance. On Friday, a biopsy revealed that Todd was deteriorating fast, headed toward "fulminant hepatic failure." Without a new liver soon, he would die. The family was in no mood to learn, as they did that afternoon from Trotter, that PHP wanted Todd moved to a hospital where it had a capitation contract limiting their financial exposure. Trotter would not tell Kim exactly where they wanted...
Hepatologist Trotter told Richard O'Connor, PHP's medical director, that Hunter was too sick to travel. O'Connor replied that the patient could stay at Duke through the weekend, but if he stabilized during that time, PHP wanted him flown to Tuscaloosa, Ala., on Tuesday. O'Connor also told Trotter, according to the insurer, that if Hunter's condition worsened over the weekend, Duke was "authorized" to perform a transplant...