Susan R. Miller
January 15, 1999

Humana reverses policy, agrees to pay for life saving double transplant operation for diabetics

While Humana has not acknowledged it, Richard Simeone, an attorney for a South Florida man who underwent the life-saving kidney-pancreas transplant surgery on Wednesday after Humana agreed to pay for it, said he was told by Humana's attorney that the company has decided it will cover the procedure. The company also has agreed to pay for another South Florida man's double transplant.

That decision apparently has been made ‹ after such attention.

Both men, as the Daily Business Review reported last month, sued Humana over its denial of the transplants. One of the men became the subject of a new national television show's satirical take on Humana.

On Wednesday, Ernesto Padron of Hallandale underwent the double-transplant operation at the University of Miami/Jackson Memorial Medical Center after Humana agreed to pay for the surgery. Another South Florida man, Christopher Donahue, ot Boynton Beach, hopes to undergo the same operation as soon as a suitable donor is found.

Both men were placed on the University of Miami's organ transplant list in the past few weeks after Humana sent a letter stating it would pay for the surgeries, said Jane Colona, UM's kidney and kidney-pancreas transplant coordinator.

Previously, Humana had agreed to pay only for the kidney, but not the pancreas portion of the operation, saying pancreas transplants are experimental and therefore not a covered benefit. But doctors said that without the pancreas ‹ the organ that produces insulin, which diabetics lack ‹ a new kidney eventually would also go bad.

Both men have suffered from diabetes since they were teenagers and are in failing health. Last year, Padron underwent heart surgery for a condition caused by the disease. He has begun to lose hie eyesight. Donahue suffers from hypoglycemia unawareness, a condition in which his blood sugar level plummets without any of the usual warning signs. He could o into a coma at any time.

When Humana refused to cover their operations, the men turned to the courts for help, filing lawsuits against Humana.

Donahue's attorney, C. David Durkee of Angones, Hunter, McClure, Lynch & Williams in Miami, dropped Donahue's suit against Humana and agreed to waive further legal action. Because he and his client signed a confidentiality agreement, Durkee declined to talk about the deal. However, with regard to Humana spokesman Donaldson's comment, Durkees said: "I believe all insurance companies should periodically review and adjust coverage to medical science. If that's Humana's position then I think it's commendable and I think other HMOs and all insurance companies should take that pro-active approach to helping their insureds."

Simeone of Tripp, Scott, Conklin & Smith in Fort Lauderdale, who represents Padron, said he didn't sign a confidentiality agreement and wouldn't agree to waive legal action.

"They have denied that they have to provide coverage, but have agreed to provide coverage," Simeone said. "We are beginning to prepare a complaint for damages."

Simeone said that Humana's lawyers told him that the company's Internal reviews committee had decided to cover kidney-pancreas transplants for diabetics who need it.

Glenn Waldman, of Waldman Feluren & Trigoboff in Fort Lauderdale, a local attorney for Humana, didn't return telephone calls.

Dr. Linda Peeno, a former medical reviewer for Humana who now chairs the University of Louisville Ethics Committee, said Humana's decision to cover the transplants was "too coincidental" in light of the media coverage and the law suits.

"If they had made the original decision on solid groundŠ they would have stood by that [decision] and not buckled under," Peeno said.

Peeno said when she worked for Humana in 1987, medical reviewers were expected to deny at least 10 percent of all claims.

"You knew that your job was linked to that performance," Peeno said. "We were told that the physician reviewer who had the highest denial rate would get a Christmas bonus."

Peeno said that she didn't stick around long enough to find out if she was in contention for the bonus, quitting less than a year after she started working for Humana. She now does health care consulting work, lectures, and teaches. She also has testified before Congress about the managed care industry.

The HMO industry long has argued that it must be able to place limits on the services it covers, otherwise health care premiums will skyrocket, forcing others to drop coverage.

"If you get transplants on demand, you have to expect premiums to go up," said Gary Davis, a health care lawyer with Steel Hector & Davis in Miami. "It's like a balloon, if you squeeze it on one end, it will come out the other."

As a result of the story in the Review, Donahue was contacted by Michael Moore, the activist filmmaker behind the documentary "Roger & Me", a biting look at the effect of General Motors on the city of Flint, Mich.

The 34-year-old Donahue will be featured in an upcoming segment of Moore's new television show, titled "The Awful Truth".

Moore, who is known for outlandish stunts, including driving a bus full of gay men having sex through states where sodomy is illegal, staged a mock funeral for Donahue.

"They had me go look at caskets and do an interview with a funeral director," said Donahue, who took it all in stride.

They later visited Humana's headquarters in Louisville for a meeting with Humana executives and to invite them to the funeral.

Tia Lessin, Moore's segment producer, said the idea was to drive home to Humana the seriousness of the situation.

"The bottom line is that Humana wasn't willing to pay for Chris' treatment so Michael and Chris went to Humana to see of they would come to his funeral because essentially they had sentenced him to death by denying him care," Lessin said.

Donaldson said Moore's show tricked Humana to get the interview with its executives.

"Mr. Moore and his entourage lied about what they wanted to talk to Humana about and misrepresented themselves," he said.

Moore wasn't available for comment, but through a representative at United Broadcasting in New York, he said he was happy about Humana's decision to cover Donahue's surgery and added: "I am thinking about making it a weekly feature where we save one life from the HMOs."