The Biggest Fight of Shotgun's Life

By Barrett Seaman

William Hunter, called "Todd" but also known to wrestling fans in his hometown of Greenville, S.C., as "Shotgun Shane Sawyer," sees the light of day for the first time in nearly a week. Above the television set on the wall opposite his bed in the surgical ICU ward, he also sees something else: an angel.

It was rolling around, folding and unfolding its wings, Todd recalled later, after the ventilator was removed from his mouth and his voice was coming back.

"C'mon, boy!" the angel was calling down to him. "It's not your time! It's not your time!"

It very nearly was Hunter's time. A video-game repairman when not delivering elbow smashes in Greenville's Southern Carolina Wrestling arena, Hunter, 27, began to feel sick back in mid-August, went to his family doctor, had tests and was told he had a liver problem. He checked into Greenville Memorial Hospital, where his enzyme levels were monitored.

What precisely caused Hunter's liver to go bad would never be firmly established, though his doctors speculated that an antiseizure medication he had been taking might have played a role. What was important was that he was getting sicker. His doctor at Greenville Memorial decided that Hunter should be in a hospital where liver transplants are done. The nearest one was the Medical University of South Carolina in Charleston. The question of insurance was not a consideration in his decision.

At MUSC, Hunter became a patient of Dr. Adrian Rubin, who agreed with the Greenville doctor that Hunter needed a new liver but who also recognized that insurance was very much a factor. Rubin consulted with the hospital's financial staff, which confirmed that MUSC did not have a liver-transplant contract with Hunter's carrier, Physician's Health Plan. But, Rubin was told, Duke, where he knew the liver people, did have a PHP contract. So the physician recommended that Hunter go there. Rubin placed a call to Duke hepatologist James Trotter, explaining that he had a seriously ill transplant candidate and that he understood that the insurer, PHP, had a contract with Duke to do liver transplants. Trotter, according to Rubin, said he recognized PHP as a Duke contractor and arranged to have a plane pick Hunter up in Charleston. It was nearly midnight, Sept. 2, when Hunter checked in to the surgical ICU ward at Duke in Durham, N.C.

SEPT. 3 A phone call from Joe Robbins, a Duke financial coordinator, to Jackie Brown, PHP's transplant coordinator, was the first anyone at the insurance company knew of Hunter's whereabouts. Both recognized that the patient was "out of network," but it would be weeks before anyone would sort out how it was that Hunter ended up in a hospital with no plan to pay for an operation that could cost anywhere from $80,000, if the procedure went smoothly, to perhaps $1 million, if complications arose. The precipitating error apparently took place in the back offices of MUSC in Charleston, where someone misidentified Duke as a PHP contractor. One possibility is that PHP's contract with Duke to do bone-marrow transplants was misconstrued as a liver contract. Another is that Physician's Health Plan was confused with another provider that is also sometimes referred to as PHP: Partners National Health Plan, a North Carolina insurer that does have a liver-transplant contract with Duke. "It's an alphabet soup out there," complains Karyn Bowie, director of managed care at MUSC. "The complexity of the system and how rapidly it changes from one day to the next make the job very tough," says MUSC's Dr. Rubin.

Such confusions are the loose cog in the vastly complicated machinery of managed care, and the cause of more breakdowns--and personal agony--than anyone would care to admit. "This is reality," says Duke's Trotter. "This happens all the time."

Todd's wife Kim, along with his parents, followed him to Durham, where they all checked into a double room at the Brookwood Inn, about 500 yds. from the Duke Hospital entrance. On Friday, a biopsy revealed that Todd was deteriorating fast, headed toward "fulminant hepatic failure." Without a new liver soon, he would die. The family was in no mood to learn, as they did that afternoon from Trotter, that PHP wanted Todd moved to a hospital where it had a capitation contract limiting their financial exposure. Trotter would not tell Kim exactly where they wanted him to go, but it was the University of Alabama Medical Center, approximately 600 miles away.

Hepatologist Trotter told Richard O'Connor, PHP's medical director, that Hunter was too sick to travel. O'Connor replied that the patient could stay at Duke through the weekend, but if he stabilized during that time, PHP wanted him flown to Tuscaloosa, Ala., on Tuesday. O'Connor also told Trotter, according to the insurer, that if Hunter's condition worsened over the weekend, Duke was "authorized" to perform a transplant.

Then, within hours, O'Connor was back on the phone telling Trotter that PHP wanted Hunter moved--not to Alabama this time but to the University of North Carolina Medical Center, a mere 20 minutes away.

Why PHP didn't ask that Hunter be sent to Chapel Hill, N.C., in the first place and why PHP's "authorization" was not a simple solution to the problem say a lot about managed-care coverage. O'Connor was unaware that his own company had a liver-transplant contract with UNC because it was really not his company that held such contracts in the first place. In the managed-care business, general-health insurers like PHP often farm out high-cost specialties like organ transplants to secondary insurers who "carve out" coverage of these procedures and do separate deals with hospitals. In this case, PHP sold its liver business to Minnesota's Minneapolis-based United Resources Network, a subsidiary of the giant United HealthCare Services, Inc. Unbeknown to O'Connor, only days before, URN had cut a deal with UNC.

But if PHP had already cleared Duke to do Hunter's transplant, why move him at all? Because PHP's go-ahead was offered on its terms, which put a cap on the amount of money the insurer would pay Duke, no matter what the operation ended up costing. While neither side has been willing to reveal what those terms were, it's a good bet that the number was on the low end of what Duke was likely to spend; on average, Duke's bill for a liver transplant runs about $150,000.

Trotter and Betsy Tuttle, the transplant surgeon who would eventually operate on Hunter, were determined to do what was medically necessary. But on the business end, there was no agreement about payment.

On Saturday, Hunter slipped into a coma. Dr. Tuttle upgraded him to highest-priority status and put out a call through the organ-transplant network for a liver. Labor Day weekend, normally a period offering a bumper crop of organs because of holiday traffic deaths, came and went without a prospect. TUESDAY 10:00 A.M. Todd remains in a coma, his liver shot, his skin yellow to his toes. Retribution is in the air midmorning when Brown reaches Trotter, demanding to know why Hunter is not at UNC. Their conversation is "spirited," according to Trotter, "emotionally charged," according to PHP. O'Connor intervenes, working through Robbins in the Duke business office to calm the waters.

Kim Hunter, meanwhile, is desperate. Her attempts to reach Brown at PHP on Friday were thwarted, she says, by a full voice-mail queue. She wants her husband to stay at Duke under the care of Drs. Trotter and Tuttle, whom she trusts. When a woman at PHP she believes was Brown finally returned her call Tuesday afternoon on the pay phone near the surgery ward, her message to Kim was that PHP "had a deal" with Duke that if it hadn't transplanted Todd over the weekend, it would move him to unc. "It felt like they were trying to make me doubt the doctors," says Kim, who is 26.

"I don't make deals," Tuttle said. "I'm going to take care of him. He's my patient." As of Tuesday night, however, there was no liver in sight, and time was running out.

WEDNESDAY 10:05 A.M. Tuttle is in the OR, assisting in the Jacks "living-related" transplant, when word comes that a liver has been located on the West Coast and can be in Durham by evening. It arrives in a large styrofoam box, bathed in preservative inside a plastic bag--surprisingly mundane packaging for a gift of life. It is after 11 p.m. when Tuttle removes Hunter's shriveled liver and begins the delicate work of suturing all the various vessels and ducts from the new liver into Hunter's system. At 12:30 in the morning, the moment of truth arrives when the clamps are removed and blood is allowed to flow into the new organ. It works--at least for now. It will be three or four days before they can tell if Hunter's body will accept it.

After a break, in which she consumes her standard post-op refreshment--grape juice mixed with Fresca--Tuttle walks down a flight of stairs and into the dimly lit and nearly deserted waiting room. "I know you're exhausted," she tells a pale Kim Hunter. "He's doing fine. The new liver is in, and the old one is out. He's been stable the whole time. We have two more hookups to go." She hugs Kim, who tells the doctor, "I ain't leaving. Thank you."

While Hunter has a new liver, the question of who will pay for it lingers on. PHP insists that it told Duke it would pay. But pay what? "They made an offer," says Robbins. "But they never agreed to pay the hospital bill." PHP fires back that anyone in the business knows that if an insurer "authorizes" a procedure, it means the patient is no longer liable, the hospital will get paid--something. Complicating this particular case is the fact that URN, PHP's liver carrier, has been negotiating with Duke over a liver-capitation deal for months, and neither side wants an individual case to take control of that process.

SUNDAY 11:45 A.M. Kim Hunter is back at her husband's side in surgical ICU. He is earnestly retelling the story of his encounter with an angel, which Tuttle has heard. "Sometimes this immunosuppression stuff makes you wacko," she confides, then adds quickly, "but some of this is interesting."

After exhorting him back to consciousness, the angel lifted him up out of his bed, Hunter excitedly tells visitors, and carried him right up through the roof of Duke North, out into the morning light, where his wife and sister and parents were waiting. They were laughing and crying together in the joy that he was back. "It's like being born all over again," says Hunter. Kim allows that they are members of Russell Memorial Presbyterian Church back in Greenville but that Todd hadn't been in a while. "I wasn't a churchgoer before, but I am now," declares Hunter. "This here has changed my life."

In so many, many ways. Assuming his new liver takes, which to date it has, Hunter will be on immunosuppressants for the rest of his life. In the first year alone, that will cost him about $1,500 a month. The likelihood that, as Shotgun Shane Sawyer, he will ever again wrestle is virtually nil. As he heals physically, he must be on guard for the intense feelings of anger, even depression, that typically besiege transplant patients. And he should make peace with his managed-care provider as soon as possible. For someone with a "pre-existing" medical condition like Hunter's, the odds of switching insurers are probably less than the odds of an angel dancing on the walls of a Duke ICU.

--By Barrett Seaman