Teacher fighting health group over medical bill

Thursday, Dec. 16, 2004 | 10:40 a.m.

When Spring Valley High School teacher Travis Underwood needed heart surgery this fall his health care plan, the Teachers Health Trust, gave him a list of 10 approved local providers it said could perform the mitral valve replacement he required.

The problem was that the surgeon that 27-year-old Underwood wanted -- Dr. Craig Miller of Stanford Hospital -- wasn't on the list. Stanford's heart clinic was rated the nation's 10th best by U.S. News & World Report earlier this year.

So Underwood went to Northern California, trading the $450 co-pay he would likely have faced had he used a network provider for a $139,000 bill from Stanford. The Teachers Health Trust covered $16,000 of expenses, leaving Underwood responsible for the remaining $123,000.

"I made the only decision I could make after talking with my doctors and my family," said Underwood, who received a mechanical valve Oct. 13. "I needed to go to California for my best chance of surviving."

Now Underwood faces years of debt and has hired an attorney to help him fight the Teachers Health Trust's decision not to cover his full expenses.

Peter Alpert, chief executive officer of the Teachers Health Trust, said while he empathized with Underwood's situation, there were many surgeons in the Las Vegas area capable of performing the procedure.

"We've paid for the surgery numerous times for other people here in Las Vegas," Alpert said. "But Stanford is where Mr. Underwood wanted to go, Stanford is where he went and now there are financial consequences to deal with."

Alpert declined to discuss Underwood's situation in more detail, saying it involved an ongoing dispute that could result in a lawsuit against the health trust.

Underwood has known since childhood that his mitral valve -- which controls the flow of blood into the heart's left valve and atrium -- would eventually need to be replaced. But Underwood's doctors had predicted it wouldn't become a necessity until he reached his 60s or even 70s.

So it was a surprise during a routine exam in August when his local cardiologist, Dr. Stephen Shiroff, discovered Underwood's condition had suddenly worsened and surgery had become imperative.

Shiroff encouraged Underwood to have his procedure done at Stanford, if possible.

Shiroff said Tuesday he has a professional relationship with Miller, the Stanford surgeon who performed Underwood's procedure, that stretches back 20 years. Miller, who specializes in valve repair and replacement, travels the world teaching other surgeons the latest techniques, Shiroff said.

"I've never lost a patient I've sent to Stanford for valve surgery," Shiroff said.

The decision to recommend that Underwood leave town for treatment did not stem from a lack of confidence in local surgeons, Shiroff said.

"I've had multiple surgeries in Las Vegas -- I stay right here for the majority of my own medical care and I'm comfortable with that," Shiroff said. "But every patient and every procedure is different and in this case I felt the right place for Travis was at Stanford."

UCLA Medical Center would have been a less expensive out-of-town option for Underwood. The Teachers Health Trust has a contract with UCLA Medical Center for services and procedures that cannot be provided locally, Alpert said.

But UCLA was never on the table, Underwood said.

Prior to his surgery Underwood filed a complaint with Gov. Kenny Guinn's Consumer Health Assistance office. In a letter to Underwood dated Oct. 14 -- the day after Underwood had the surgery -- Paulette Gromniak, a quality assurance specialist with the office, said she reviewed the Teachers Health Trust plan and spoke with Alpert.

"There were not any non-compliance issues with the health plan noted," Gromniak wrote.

"It was determined that, as you know, the services were available in-network and therefore the request for approval to reimburse at the higher benefit would be denied," Gromniak's letter states. "Mr. Alpert also mentioned that UCLA was an option for you."

"The first time we heard UCLA mentioned was in that letter," Underwood said.

A Clark County School District teacher for four years and a 1995 graduate of Chaparral High School, Underwood also coaches volleyball and soccer. He and his wife, Michelle, are expecting their first child in February -- Underwood also has an 8-year-old son from a prior relationship.

Underwood makes $32,397 annually. He said family and friends dipped deep into their own reserves to pull together the $74,000 down payment required by Stanford for admittance.

Spring Valley High School's student council has launched "Operation Underwood," a campaign to help collect contributions to off-set the medical costs their teacher has incurred. Underwood, who hopes to be back in the classroom after the winter break, said he was "overwhelmed" by the gesture.

"We've been very fortunate in the support we've gotten from everyone," Underwood said. "You hear feel-good stories all the time, but when it's actually happening to you it's an incredible experience."

Underwood pays for the "PPO Plus" plan, the Teachers Health Trust's top level of coverage offering a broader list of providers. However, if members seeks treatment outside the network, the plan's administrators determine reimbursements based on what is "reasonable and customary."

Underwood said Stanford offered the Teachers Health Trust a one-time contract that would let the hospital charge the reduced rates offered to its own network members. But the offer was rejected, Underwood said, because Stanford's rates -- between $2,000 and $8,000 a day -- were significantly higher than the $1,350 daily rate the Teachers Health Trust was prepared to pay.

Underwood's situation highlights the difficulties of modern managed health care, where insurers negotiate drastically reduced rates with a limited number of providers, said Larry Matheis, executive director of the Nevada State Medical Association.

Giving patients the opportunity to choose a caregiver they trust is a factor that is often undervalued by insurance providers, Matheis said.

"The payers put the principal weight on getting the prices they want for services," Matheis said. "That's not unimportant but in the balance a great deal is lost on the patient's end of the scale."

Consumer advocacy groups nationwide are pushing for change, Matheis said.

"Patients and families want health plans to consider more than just economic factors when determining what services will be covered," Matheis said. "There should also be comparisons of the training and experience a physician has, the support systems of the hospitals where they work. That's information that should be shared."