Twins’ Mom Wins Fight Over Home Care

A Covina mother of 10-year-old twins with rare lung and heart ailments has won her fight with a powerful state agency that refused to pay for home nursing care that the children’s doctor said was needed to keep them alive.

The state’s giant pension fund, the California Public Employees Retirement System, will pay for the care, spokeswoman Patricia Macht said.

The case helped convince CalPERS--which purchases health care for about 1 million government employees, retirees and their dependents--to improve its appeals process for members who are denied medical services, Macht said. “We have some issues with the way this case was handled,” she said.

CalPERS is one of the largest and most influential purchasers of health care in the country and its policies are closely watched by medical insurers.

In January 1994, Linda Sarver sued CalPERS, Blue Shield of California (which administers claims for the state agency) and a medical review company after the insurer determined that home nursing services for the twins were not “medically necessary.”

Terms of the settlement, reached late Tuesday, were not disclosed. Sarver and her lawyers have said previously that they would go to trial if CalPERS and Blue Shield did not agree to pay the nearly $200,000 annual bill for nursing services as long as needed.

The case touched on issues that are raging in the medical community as an increasing number of Americans sign up for managed health care. Among them: When should an insurer be able to ignore medical decisions made by a patient’s treating doctor? Also, should patients’ appeals of treatment denials be ruled on by third parties that may have a financial incentive to limit treatment?

“This is a battle we fight with many HMOs and managed-care companies,” said William Shernoff, a Claremont lawyer who represented Sarver and her sons, Bradley and Steven. “You have administrators, executives, retired doctors--or people with a bias--overruling a doctor’s judgment as to what is appropriate treatment.”

Since birth, the Sarver twins have suffered from a central nervous system disorder that puts them at risk of lung or heart failure every time they go to sleep. Michael Bowman, a pediatric pulmonologist at Children’s Hospital of Los Angeles who has treated the twins for nine years, has said they suffer from sleep apnea, or cessation of breathing, and bradycardia, a slow heartbeat.

Each night, they are hooked to monitors that sound screeching alarms whenever their breathing or heart rates dip below certain rates. The alarms go off hundreds of times a night, requiring a nurse to intervene by rousing the boys until their heart and breathing rates return to safe levels, according to Bowman and court documents.

The Sarver twins are otherwise healthy. They are honor students at a Covina elementary school, play Little League baseball and take acting lessons.

The insurance problems began after Sarver’s former husband’s employer, the city of Beverly Hills, switched medical plans.

In November 1993, Healthmarc, a company that reviews disputed medical claims for Blue Shield, determined that the twins’ nighttime nursing care was no longer medically necessary. Sarver appealed the decision, and four doctors who reviewed the case for Healthmarc and Blue Shield also found the care to be medically unnecessary.

Bowman wrote the insurer a letter on Nov. 4, saying the insurer’s denial “markedly [increased] the risk that an event will occur which makes either or both boys a vegetable or a corpse.”

In March 1994, a Los Angeles County Superior Court judge ordered CalPERS to pay for the home health care until the lawsuit was resolved.

Sarver’s lawyers contend that the Healthmarc and Blue Shield doctors were unqualified to review a case as complicated as the Sarver twins’. None of the doctors had expertise with pediatric heart and lung problems; one doctor who reviewed the case for Blue Shield was a 73-year-old internist who had never practiced pediatric medicine, said Theresa Barta, another lawyer for Sarver.

“I don’t think any of these doctors were qualified to make the call,” Barta said. “There are plenty of doctors out there who would have been qualified.”

CalPERS, Macht noted, “is not the front-line decision maker on issues of medical care. We rely heavily on folks like Blue Shield and Healthmarc. In many cases, they do a very good job.”

Shernoff and Barta also contended that the CalPERS contract with Blue Shield, which they obtained during discovery research on the case, included “savings clauses” that “created a pool of money which was saved by denials of coverage.” CalPERS and Blue Shield would share in the funds, they said.

But Macht denied that CalPERS has any contracts that “pay specific incentives to individuals to do that sort of thing.”

Sarver, a Covina city councilwoman, said she “was grateful that this is over. This has been a very difficult 2 1/2 years.”