SHOW:  NBC Today Show

 

DATE:  December 8, 1998

 

 

   

 

MATT LAUER, co-host:

 

We hear all the time about people's fears of managed health care, that they won't get to choose their doctor, or that the plan might put cost before treatment.  We found a story, we think, that puts a face to that fear.

 

Karen Johnson of Louisville, Kentucky, was diagnosed with cancer but her insurance company, Humana, refused to pay for her doctor's recommended treatment.  The case went to court, and a jury found that Humana had acted improperly and awarded Johnson $13 million in damages.  But the story isn't over.

 

Later this month, Humana's lawyers will be back in court to ask that that verdict be overturned.  NBC's Rehema Ellis has the story.

 

REHEMA ELLIS reporting:

 

To Karen Johnson, family is everything.

 

Ms. KAREN JOHNSON: My husband and my children are my life.  It always reminds me of--at least another year of our life's gone, Homer.

 

ELLIS: Three years ago, her life with four-year-old Natalie and seven-year-old Nathan, and her husband, Dave, was suddenly threatened.  Karen was diagnosed with cervical cancer.

 

Ms. JOHNSON: I was very scared.  I was scared I was going to die.

 

ELLIS: Karen's doctor, the man who delivered both her children, informed her of the treatment options.  He advised a hysterectomy to cure her cancer.  Anything less, he warned, put her at risk of the cancer returning.

 

Dr. BARNETT J. HYMAN (Gynecologist): The only way that I can guarantee a patient with carcinoma in Situ not to have invasive cancer is by a hysterectomy.  It's unequivocally indicated.

 

ELLIS: With so much to live for, Karen Johnson was encouraged by her doctor's words.

 

Ms. JOHNSON: To be told that you have cancer, and then to be told that there was a cure for this--this kind of cancer, was--was a breath.  There was hope.

 

ELLIS: But Karen's hope soon faded.  Her insurance company, Humana Health Care Plan, which insures more than six million people nationwide and pays $8 billion in claims every year, refused to pay for the treatment her doctor recommended.  However, Humana said it would cover another, less extensive, less expensive medical procedure, to see if that would have therapeutic results.

 

Dr. MITZI KROCKOVER (Director, Women's Health, Humana): I saw many cases like Mrs. Johnson's, and what I do know is that what she had was carcinoma in Situ.

 

Reporter: Dr. Mitzi Krockover, the former director of Women's Health at UCLA School of Medicine, is now the director of Women's Health for Humana.

 

Dr. KROCKOVER: When you look at what procedures you recommend, you have to really weigh the risks and the benefits.

 

ELLIS: In Karen Johnson's case, the risks and benefits were weighed by three different medical reviewers subcontracted by Humana.  They unanimously disagreed with the recommendation of Karen's doctor.  They recommended her plan pay only for a conization, a procedure to remove part of the cervix, not the entire uterus.  That did not require her to be hospitalized.  Instead of costing thousands of dollars, it cost only hundreds.  But Karen's doctor warned that without the hysterectomy, she still faced up to a 15 percent chance that her cancer would return.

 

Mr. DAVE JOHNSON (Husband): (Reading to child) "And if I get scared at night, my mom won't be there."

 

ELLIS: Karen and her husband did not like the odds.  They were afraid of the cancer coming back and it not being detected in time to save her life.

 

Mr. JOHNSON: She had a family, two young children, and there was no use in taking that chance.  We had paid premiums for so many years, and now they were basically abandoning us and leaving us to fend for ourselves.

 

ELLIS: Living on a modest income, the Johnsons faced a desperate choice.

Follow their doctor's advice or follow Humana's advice.  Karen decided to go with her doctor.

 

Ms. JOHNSON: There was not a question.  I did not want to play with cancer.

 

ELLIS: The surgery cost Karen over $14,000.  Because Humana declined coverage, the hospital called the Johnsons less than 24 hours before her surgery, telling her she would need $5,000 up front.

 

Ms. JOHNSON: I guess the most difficult thing was, we knew we didn't have the $5,000 and that possibly my parents could help.  But you know, it's kind of degrading to both of us to have to go ask my parents for money.

 

ELLIS: She got the money and the surgery.  But medical trauma was followed by emotional trauma and a trail of debts and bill collectors.  Frustrated and bewildered, the Johnsons decided to fight both the cancer and the insurance company.

 

The whole point of health-care insurance was to cover catastrophic illnesses and to cover unforeseen medical situations, isn't that right?

 

Dr. KROCKOVER: I think what you're alluding to is that there was some kind of denial of care, and that is not what happened.

 

ELLIS: But you did deny the coverage of the hysterectomy.

 

Dr. KROCKOVER: Denied the coverage of a procedure that was deemed

inappropriate in that setting and at that time.

 

Ms. JOHNSON: This isn't just about me, this is about the thousands of other people that this has happened to.  And I wonder where they are today.  What's happened to them?

 

ELLIS: Karen Johnson's battle against Humana went on for three years and

finally ended in court.  After a six-day trial, the jury deliberated for less than three hours, sided with Karen Johnson and awarded her more than $13 million in damages.  Humana maintains they offered Karen Johnson appropriate care, so they're asking the trial judge to disregard the jury's verdict.

 

Dr. KROCKOVER: What we did was in very good faith.  It was a legitimate

disagreement between physicians, and our recommendation was to cover the

procedure that was recommended by these three independent experts.

 

ELLIS: Dr. Linda Peeno, a former employee and now critic of Humana, charges HMOs routinely put profit over health care.

 

Dr. LINDA PEENO: There are financial decisions disguised as medical decisions.  I think that that's what we're seeing right now.

 

Dr. KROCKOVER: It's not about cutting costs.  It's about improving the health of our members.  And that's what we will continue to do.

 

ELLIS: Karen Johnson's lawyers say the jury's verdict, one of the largest ever against a managed-care company, should be a lesson to all managed health care.

 

Ms. JANICE WEISS (Attorney): To put the medicine back in the hands of doctors and patients.  It's that simple.

 

Ms. JOHNSON: Good job, Nathan.

 

ELLIS: For the Johnsons, the verdict was about family and justice.

 

Mr. JOHNSON: Good job.

 

Ms. JOHNSON: This is about people, and love, and livelihood, and good health and--and keeping families healthy and well.

 

ELLIS: Karen Johnson appears to have won her battle against cancer, but the fight is far from over.  For TODAY, Rehema Ellis, NBC News, Louisville, Kentucky.

 

LAUER: It is 8:15.  We're back with more of TODAY right after this.

 

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