Patients Find New Ways|
to Battle HMO Denials
By Karen Winner
Mary Halm was in a medical bind. Her doctor had referred her to an out-of-state specialist who treats internal scar tissue. But her health maintenance organization rejected the referral -- twice.
Halm invoked her right to a formal review of the decision under her HMO contract and state law in Ohio, where she lives near Columbus. But as the process dragged on, the pain from a condition called endometriosis, a disease of the female organs that causes internal bleeding and builds up scar tissue, became so severe that Halm could sleep at night only by curling up into a ball on the couch, she recalled.
Nine months after filing the grievance, she heard the final word -- no. Halm said she then borrowed $10,000 to pay for the specialized surgery herself, which she underwent in Atlanta on Feb. 12 of this year.
"I feel better now than I have for four years," she said. "I can sleep in bed again. It's incredible."
Cases like Halm's have caused intense worry over HMO red tape and delays and the dearth of information about the complaint process itself. President Clinton in February issued an executive order creating a "patient bill of rights" for the 85 million people in federal health programs, including federal workers and people in programs such as Medicaid. The Clinton administration is also pushing Congress to adopt a patient bill of rights for all health care consumers.
Among other things, the order upholds the right of consumers to speedy appeals when managed-care companies deny coverage and, if necessary, to a hearing by an independent review board.
Halm thought she already had that right under Ohio law as well as her contract with the HMO, Community Health Plan of Ohio. But she learned otherwise.
In a letter to the Ohio Department of Insurance, the HMO admitted to delays in her case, citing what it termed "inexperienced staff" and high turnover in the past year. "While this is not an excuse, it is merely an explanation of some of the difficulty incurred throughout this process," said the Dec. 15 letter that Halm obtained from the department.
But the HMO has stood by its final decision to deny Halm coverage of the surgery in Atlanta. Dr. Robert Kamps, president and chief executive officer of Community Health Plan, said the surgery Halm needed could have been obtained through an HMO provider at Ohio State University Hospital.
"It distresses me when we get complaints. We get very few of them," Kamps said.
Halm said the doctor recommended by the HMO was not a specialist in endometriosis. She said her primary care physician urged her strongly to seek out the surgeon in Atlanta, who performed a special laser technique called laparascopic microsurgery (which requires only minute incisions).
Every state requires HMOs to set up grievance procedures of some kind for complaints by consumers, according to research conducted by the Families USA Foundation, a nonprofit group in Washington. But often the requirements are easy to evade, and several states have taken steps to stiffen the rules.
Texas, Connecticut and Missouri, for example, allow consumers to go outside the HMO to seek speedy reviews from independent boards of physicians and other health care practitioners that could overturn the HMO's decision. New York and Illinois are currently proposing similar legislation.
Don White, spokesman for the American Association of Health Plans in Washington, agreed with the need for orderly and timely grievance procedures, but said external reviews by independent boards are unnecessary.
"What we're talking about here is a very small percentage of total grievances," said the managed-care industry spokesman, adding that appeals usually get resolved within the internal grievance process "to everyone's satisfaction."
Last year, New York passed an HMO reform bill that set rules for grievance procedures, without calling for external review boards. Health policy advocates say the provisions have fallen short of protecting consumers, partly because of lax enforcement by the state.
"The problem here in New York is that we don't get a sense that anybody is monitoring the plans to see that they're complying with the law and enforcing the law," said Mark Hannay, director of the Metro New York Health Care for All Campaign, a coalition of advocacy organizations and labor unions.
State regulators deny the charge. "We will do undercover stings to ensure that one of the most comprehensive bills in the nation is implemented and complied with," said Robert Hinckley, spokesman for the New York Health Department. He said the state already conducts routine checks on managed care companies to ensure compliance.
New York's Managed Care Consumer's Bill of Rights was conceived as a sweeping reform with specific provisions to improve grievance procedures. Among them: a toll free number that consumers can call to file a grievance with the HMO; access to information on how long an appeal will take; the right to appeal the decision; the right to pick an advocate to represent the consumer in the appeal process.
Those who claim the provisions are lacking enforcement point to a December 1997 report by a task force of private and professional organizations that concluded: "Unfortunately, in New York, some managed care organizations provide very little information about grievance processes, while others sometimes provide incorrect information."
The report, "How to Make Managed Care in New York Consumer Friendly," was prepared by agencies including the Legal Aid Society and The National Association of Social Workers.
Concern over grievance procedures has prompted social workers in New York to begin their own private inquiries into HMO practices.
The national association has created "critical incident forms" being distributed to 30,000 social workers who are asking clients to fill them out with details about their tussles with managed-care companies.
After the forms are returned, the information will be analyzed and shared with the public and government officials, according to Penny Schwartz, a spokeswoman for the city's chapter of the national association.
Despite the problems, Schwartz still believes HMOs can be made to work for consumers.
"Look, managed care is here and I don't know how long it's here for but it's certainly here now," Schwartz said. "I would say it has the potential in its design to be a revolutionary way of delivering health care.
"It has the potential to be excellent in the sense of giving good preventive and primary care," she said. "However, the question remains, and remember this is a laboratory -- Can we deliver on that potential?"
Halm, who lives in Chillicothe, Ohio, doesn't have the answer. She's just mad. "It's unacceptable," Halm said, adding that she is mulling a lawsuit against the Ohio HMO.
Posted: June 23, 1998