Questions Remain In Death Of Patient

Jan 25, 2016

The story of Maria Huaman has set off a score of comments online, criticizing everything from Jackson Memorial Hospital to the organ transplant process.

Huaman died on Jan. 13 at West Kendall Baptist Hospital. According to Huaman's family, Maria was denied a transfer to Jackson for a lung transplant. Why she was denied comes from the family because the hospital has not spoken.

Did the hospital ask questions that were prohibited, such as ask about Huaman's legal status, or if she had insurance? Daniel Chang of the Miami Herald looked into the case and talked about why some people are missing the true focus of the story when they just focus on organ transplants.

Take us through how she ended up dying while waiting to be admitted into Jackson Memorial.

Well what happened was that she was admitted to West Kendall Baptist Hospital through the emergency room on Dec. 18. She had been feeling nauseous and vomiting. And just before that, in fact, she had gone to an urgent care center where they had diagnosed her with  kidney failure. So she was taken by ambulance to the emergency room. She was in the hospital for more than three weeks  beginning around Jan. 5. Doctors at Baptist felt that she was beyond their ability to care for  and they recommended that she be evaluated for a lung transplant,  and there's only one place in South Florida where you can do that and that's the Miami Transplant Institute, which is a partnership of Jackson Health System and the University of Miami. That's typically a very long process, and even if people get on a waiting list there's no guarantee that they will receive an organ that will match them and there's no guarantee that that they will actually live beyond whatever their natural state was. But that wasn't the point of the story. The point was that the family was never told that she was denied for medical reasons until at least five days after they had been requesting,  according to her family. She had or they had first been denied because Jackson Health felt that she was an undocumented immigrant.

They asked her, are you a documented immigrant?

Well,  there's a reason why they asked her. That's because on Dec. 17, the day before she went to Baptist and the urgent center where they diagnosed her with kidney failure she had gone to Jackson South Community Hospital and she was held there for several hours. According to her husband and father-in-law, they did several tests on her. They held her for observation and then they discharged her with a prescription for heartburn medication. But see,  when she was at Jackson South, according to Jackson, she had misrepresented herself as being an undocumented immigrant. And the family says no, that she was a legal permanent resident;  she had actually received her residency in June of 2014.

Is Jackson allowed to ask that question?

Jackson is not supposed to ask that question when folks come up. When Miami-Dade residents appear in their emergency room and they do not have insurance. Jackson will screen them for whatever type of public financial aid they can receive. But, under their mission, they are not supposed to ask about you or your legal status as an immigrant. The only requirement is that you be a Miami-Dade resident and then you can qualify for what's called charity care, which is free or reduced-cost care depending on your income. And it's not entirely clear. I've asked Jackson and they haven't answered whether you can qualify for a transplant if you received charity care. Charity care is supposed to be like insurance,  but it's really not as good as having private health insurance or even Medicaid.

Have you heard from the hospital yet? Or are they talking at all?

Well,  the hospital is not allowed to talk about specific patients because of the Health Insurance Portability and Accountability Act or HIPAA. They [the Huaman family] told me that they were going to sign a waiver in order to allow Jackson to speak to me more specifically about this case. And they didn't fill out all the required forms and I think that frankly they're a little exasperated with the whole experience.

Let's look at the issue about asking her about her insurance. This is a hospital that's supposed to serve the uninsured well,  right?

Carlos Marquez is overcome with grief as he talks about the recent death of his daughter-in-law, Maria Huaman.

  That's right. Jackson receives property taxes and sales taxes from Miami-Dade County residents in part so that it can help care for our uninsured now because Miami-Dade has a lot of uninsured individuals and a lot of low-income individuals. It's really not enough. They will receive about $400 million this year in what they're projecting,  and I think what needs to happen is a public conversation in terms of what are we going to do with limited resources about caring for our uninsured Miami-Dade residents, and if we want to start screening them for immigration status and other issues and we should make that known and talk about it publicly. And this situation is only going to get worse because, you know, we're losing federal aid.  The largest pot of federal aid that we get to help pay for the uninsured is called the Low Income Pool and it is shrinking. It's going to be reduced from $1 billion this year statewide to $600 million next year.

The other thing you pointed out in your story is the hospital asked for a down payment of $350,000. Is that's normal?

According to the United Network of Organ Sharing  a federally contracted overseer of the transplantation process for all transplant centers in the United States, it's not uncommon to ask for a down payment and that is because transplants are extremely expensive. This is one of the most expensive procedures probably that you can get. I found an actuarial report from Milliman, which is contracted  with the state to help them figure out their Medicaid rate, so they know health care very well. It estimated lung transplants cost in 2014 between $700,000 and $1 million. Now that's 30 days pre-op surgery and then follow-up care for at least another month or so,  and the reason that a lot of transplant centers across the United States -- not just Miami Transplant Institute -- prefer that their patients be insured or will ask for a down payment is because it's very expensive and it's risky and it requires a lifetime of follow-up care. You have to take a amino-suppressant drugs so that you don't reject the organ. You have to follow up with doctor's visits and it's, it's really a lifetime of care and they need to plan for that.

Were they asking about her immigration status and then about her insurance and then about this deposit all together at once,  or  how did this happen?

This was over at least five days. First the family says they were rejected because she had been listed as an undocumented immigrant at Jackson South. Once they cleared that up they said, well she doesn't have insurance. She can't support transplant surgery and the post-operative transplant care. There's an unfortunate tale in this story which is that Maria, because she's a legal permanent resident in the country fewer than five years, she was eligible for tax credits to buy a plan on the Affordable Care Act on its insurance exchanges. She didn't know that. Their income for their family, she and her husband and their three children, was less than $28,000 in 2015, so they fell below the federal requirement for citizens to receive a subsidy. So they were basically in the coverage gap. It wasn't until after they were rejected for not having insurance and they met with the navigator that they discovered that she was eligible. She found a plan for $8 a month essentially after her federal subsidy. And I'm sure that if she had been insured we wouldn't be hearing about this case. It doesn't guarantee that she would have survived. It doesn't guarantee that Jackson would have admitted her,  but I think that the family would have gotten a sense that she was valued as a person and got a fair medical evaluation rather than being rejected for being,  you know,  an illegal immigrant and being uninsured.

It almost seemed like the hospital was trying to find a reason not to admit her. Did they drop the ball on this or is this just procedure?

Maria Huaman, 38, of Miami, left, in a photograph with her husband
Credit Miami Herald

  Look, I don't know enough to say, especially without Jackson being able to address this case specifically. What I can say is that the policy that they have now and the expectation that Miami-Dade residents have now is that if you are uninsured and you show up at Jackson -- and it's also the law, by the way, under the Affordable Care Act, you’re supposed to inform people about your charity-care program. Now the law doesn't say how rich that program has to be; it doesn't stipulate what it has to cover. But you need to at least inform people that you have a program for low-income uninsured individuals and you can screen them and qualify them financially. I think that given the type of procedure that they were requesting, I mean the lung transplant, that cost had to be a consideration. Like I said,  it's not uncommon for transplant centers to require or request a down payment or to require that their patients have health insurance because of the lifetime of expense that's incurred.

What can the family do now? Or can they do anything?

I'm not sure that there is a whole lot that they can do.

Can the hospital face any kind of fines or any kind of punishment for this? 

There's a federal law that says that anybody who shows up in an emergency room in an urgent situation the hospital must accept them and stabilize them. This is for all hospitals --  privately owned, non-profits, publicly funded hospitals. All have to live by this requirement,  but there is an exemption for transplantations [which] are really not an emergency medical procedure. If you're in an emergency,  you know a transplant can take so long because there's no guarantee that you're going to find a donor match. You can't offer that as an emergency service because you never know when the organ will become available,  and there are always way more people waiting for organs than there are actually organs available. So for that particular type of procedure it does not apply. You know the lack of Medicaid expansion in Florida also would have probably resulted in a different outcome,  not necessarily in her survival but certainly in the hospital not having to take the extra day or two or three. Again there was no guarantee that she was going to survive from her illness. There was no guarantee that she would find a matching organ. I think again the issue is, is that the expectation that we have of our publicly funded hospital that we give generously to through our taxes is that it live up to its mission of providing a single standard of care for all Miami residents regardless of their ability to pay.

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