ABLEnews Extra

                         The Price of Profit

     Revolutions are notorious for their victimization of the innocent
     and the unaware. The revolution that is overthrowing traditional
     fee-for-service medicine is no different. On August 27 through
     August 31, the Los Angeles Times reported on its seven-month
     investigation of California HMOs. Excerpts from the series of
     particular interest to persons concerned with the impact of
     managed care on patient care are provided below. (Ellipses have
     been omitted to facilitate reading.)

     N.B.--The entire series may be ordered by calling Times on Demand
     at 800-788-8804. The following file may be freq'd as MC50827.*
     from 1:275/14; and other BBSs that carry the ABLEFiles
     Distribution Network (AFDN) and ftp'd from ftp.icdi.wvu.edu on
     the Internet. Please allow a few days for processing.]

Scarcely a year ago, health reform in America was declared dead. The
Clinton administration's reform package, two years in the making, was
buried by Congress in a matter of months. Americans, it was said, were
not ready for a health care revolution.

But for millions of Californians, the revolution is here.

It is called managed care, and it is being advanced faster and further
here than by any other state in the union, radically transforming the
practice of medicine and patients' relationships with their
physicians.

But these changes have come at a price--a price paid by the sicker
patients, those with complicated or hard-to-diagnose conditions, and
the chronically ill.

In a seven-month investigation, The Times found that the HMOs in
California withhold some services from these patients for no other
reason than that they are expensive.

Put another way, with little public debate and scant government
oversight, the state's HMOs--squeezed by employers to cut costs--are
rationing health care to Californians.

HMOs commit themselves to providing all "medically necessary" care for
their members.

But listen to patients, doctors, and other medical professionals--read
their court testimony and the letters, faxes, and e-mail messages that
arrived by the hundreds when The Times solicited Californians' stories
about HMO care--and you will know that the health plans frequently
fall short of this ideal. Many Californian HMOs save money not only by
squeezing inefficiencies out of the system, but also by refusing
medical care, either overtly or indirectly.

Patients who could benefit from the attention of specialists have been
forced to accept "next-best" treatment from doctors not fully
qualified in the appropriate field. A urologist is assigned to perform
an operation better handled by a specialist in kidney cancers--with the
result that a tumor is punctured, worsening the patient's condition.
Specialists from cardiologists to dermatologists complain that primary
care physicians are being asked to do too much, with the result that
potentially cancerous lesions, alarming heart conditions, and other
early warning signs are being missed.

In most cases, HMOs themselves are the final authority for determining
a treatment's medical necessity--decisions they may make for their own
advantage.

Then there is the "hassle factor," an aspect of HMOs--and the medical
groups they contract with--that frustrates many. Patients needing
critical care navigate a web of rules and technicalities that can make
a day at the DMV seem like a day at the beach.

Denise Harris, and Ontario [CA] housewife, barely survived the
gauntlet, after reporting symptoms to her HMO doctors that would later
turn out to be ovarian cancer. At one point, her HMO withdrew approval
for diagnostic surgery after Harris had already been prepped for the
operation and was waiting at the hospital. Not until 10 months after
she first visited the doctor did she have surgery to remove the
malignant growth on her ovary.

"They had no regard for my life, safety, or health," she says of the
medical bureaucracy that managed her care under the aegis of Health
Net, the state's second-biggest HMO.

During pretrial proceedings in a lawsuit Harris filed, Health Net
contended that the law does not allow for damages to compensate for
delays in getting care.

HMO executives take care to avoid any suggestion that they are engaged
in rationing. For one thing allowing financial considerations to
affect medical judgment in any particular case is strictly against
state law. For another, the very word conjures up unsavory echoes of
euthanasia, of the notion that some people do not deserve to survive.

The health plans contend they are meeting employers'--and society's--
demands for lower costs. They say that most complaints about managed
care come from patients unwilling to accept the end of a decades-old
culture of "medical entitlement."

But many critics believe that the HMOs may have swung the pendulum too
far in placing economics ahead of quality of care.

As The Times has found, the patients tending to be most poorly served
by HMOs are those like Harris: victims of unusual or complex diseases
who need highly specialized treatment or carefully coordinated care.

Also poorly served by HMOs, according to many experts, are patients
suffering from such chronic conditions as arthritis or multiple
sclerosis, and patients in need of rehabilitative therapy.

In both categories, expensive treatments extend over long periods,
while recovery is likely to be slow and subtle. But some HMOs cut off
treatment when a patient plateaus--even though a specialist may say
that continued therapy will be beneficial

For the chronically ill, timely access to specialists "can make the
difference between a decent "quality-of-life" and barely surviving,"
says Laura Remson Mitchell, government issues coordinator for the
California chapter of the National Multiple Sclerosis Society.

"In extreme cases," she says, "the fact that you can't get to
appropriate providers can result in a chronic condition turning into a
fatal one. Chronic disease magnifies all the problems that exist for
everyone in HMOs."

That has been the experience of Lisa Baynes, a 38-year-old mother of
twins who was diagnosed with multiple sclerosis six years ago. Coping
with the disabling effects of the disease has been hard, the Mission
Viejo woman says. But the battles with Cigna, her HMO, at times have
been harder.

When symptoms flare, Glendale-based Cigna requires Baynes first to
schedule an appointment with her primary care doctor. If a specialist
referral is needed--as it often is--the primary care physician must get
authorization from a committee of his or her medical group that meets
periodically to review such requests. The process can take weeks.

"They beat him down," Baynes says of the reception her primary care
physician gets at these sessions. The neurologists to whom she has
been referred in her Cigna medical group have not had much experience
treating patients with multiple sclerosis, she adds.

Some national studies show that HMOs are good at treating routine
ailments for which care is widely standardized. Other studies
highlight the HMOs' shortcomings in treating chronic or unusual
maladies.

A 1994 survey of nearly 5,000 elderly patients published in the
Journal of the American Medical Association found, for example, that
HMO members suffering arthritic pain were less likely than non-HMO
members to have been referred to a specialist and less likely to "be
followed up or monitored closely."

Most important, of those still experiencing joint pain at the time of
the survey, HMO members were less likely to report any improvement in
their condition.

A recent national study by Harvard University researchers found that
patients with serious illnesses in HMOs and other managed care plans
have more difficulty getting services and treatment than people in
fee-for-service plans.

Doctors say that some HMOs try to ration care by refusing to pay for
treatments that do not promise a distinct cure. This amounts to a
radical change in medical philosophy--especially given that cancer
specialists regard patients as "cured" if they survive just five
years past the onset of the disease.

And the switch in thinking is taking place in almost the complete
absence of a public debate. 

"This goes to having an administrator, whether a doctor or not,
telling a family that your mom's life is not worth paying for because
the treatment isn't curative," said Dr. Beth Y. Karlan, head of
gynecological oncology at Cedars-Sinai Medical Center in Los Angeles.
"But is it worth it to allow a 34-year-old woman to see another
Christmas with her 5-year-old daughter? I have patients who I feel are
real triumphs because I got them another two years of life."

Karlan says she battles constantly over such treatment with the health
plans that provide her patients' coverage.

Studies also show that HMOs also tend to allow shorter and less
intensive rehabilitative therapies than accident victims, stroke
patients, and other rehab users have long expected.

A 1993 study for the US Department of Health and Human Services
concluded that stroke patients in HMOs "received significantly less
physical therapy while in the hospital and had greater motor and
speech defects at discharge, yet were not more likely to have
post-discharge speech or physical therapy planned," a pattern
suggesting "that HMOs may skimp on rehabilitative care."

Patients with chronic or complicated illnesses often find that rules
ostensibly designed to discourage the overuse of medical resources
function more as technicalities that can only be overcome by lengthy
bureaucratic battles or court intervention.

That's what happened to Harry Christie, a Silicon Valley businessman,
when his 9-year-old daughter, Carley, was diagnosed with a rare kidney
tumor in 1993. Christie demanded that his HMO, TakeCare, allow Carley
to be operated on by a leading US specialist in the tumor; the plan
refused, insisting that the procedure be done by a urologist who had
never worked on a similar condition.

Christie had [the expert surgeon] perform the operation any way--and
then spent two years in binding arbitration before Take Care was
ordered to pay the bill.

Another barrier keeping patients from effective treatment is lack of
information.

Sometimes, patients are not told the basis on which treatment is
refused by their HMO. HMOs generally do not allow patients to go
outside their own physician networks for second opinions. And doctors
who have worked in managed care say some plans deliberately restrict
what patients are told about possible treatments, less they demand a
costlier one.

"If a doctor doesn't operate, there's no disclosure to the patient
that there's an operation for your problem and we're not going to tell
you about it," says David Thomas, a San Diego surgeon who retired at
age 55 rather than continue working under managed care. "That means
there's not an event that might send the patient to get a second
opinion."

That issue arose between Kaiser and Billie J. Comer, a Northern
California employee of AT&T, when Comer's son Ryan fell ill with a
rare pediatric cancer.

Only after Ryan completed several unsuccessful courses of chemotherapy
did Comer learn of a treatment involving bone marrow transplants--by
reading an article about it in Lady's Home Journal. Kaiser doctors,
she said later, explained that they had failed to mention the therapy
because Kaiser would not pay for it any way.

In the end, Comer raised more than $100,000 to pay for the treatment
herself. By then, Ryan's disease had progressed too far for it to be
effective; he died in 1991.

Coverage of such experimental treatments is a persistent issue between
HMOs and members. 

Health Net, with 1.2 million members, was hit by a $90-million court
judgment in 1993 when a jury learned that it had denied a costly
bone-marrow transplant to breast-cancer patient Nelene Fox while
approving one for another member--who happened to be a Health Net
employee.

The plan said its decisions were based on medical evidence, but the
Fox family's lawyers produced evidence showing the HMO's managers got
bonuses for keeping treatment expenses low.

Doctors trained to be patient advocates find the system confounding;
many say the paperwork burden has shifted to them.

"It's not patient care any more, it's fighting the insurance
companies," says Dr. Sherry Braheny, chairman of the San Diego Medical
Association's committee on bioethics. "I have a four-page form to fill
out to get a wheelchair for a patient, instead of a prescription.
Everybody has found this kind of paperwork is worse" under HMOs.

Some industry leaders concede that HMOs do a woeful job of educating
their members about the limitations of their coverage. By state law,
this information must be made available to any enrollee who asks. But
in practice, it is couched in such impenetrable language that many
patients come away without understanding.

One feature that HMOs take pains to promote is their commitment to
preventive care. Health Net promotes itself as "The Wellness Company."

But many experts say HMOs' interest in prevention programs begins and
ends with their value as marketing tools.

It's a rare HMO that does not ply its members with brochures promoting
anti-smoking campaigns, weight-reduction plans, and the value of
exercise.

But far fewer maintain long-term screening programs to identify
chronic risk factors for a wide range of preventable disease, do
consistent follow-up to ensure that prescribed medications have been
taken or specialist referrals approved, or maintain computerized
databases enabling them to coordinate the care that individual
patients receive from various doctors.

In fact, the state Department of Corporations, which regulates HMOs,
has cited almost every plan it inspected over the last five years for
failures in exactly those areas. And one study by the state health
department found that immunization rates for children of Medi-Cal
recipients were lower among those treated by HMOs than those receiving
care at public clinics.

The reason, critics say, is that such programs don't pay. "To be
effective preventive care is a long-range bet," said Robert E.
Tranquada, a USC professor of medicine and public policy.
"Immunization, diet, mammography: These are mostly things that won't
provide short-term benefits."

Given the high turnover in many HMOs' patient rolls, they may see no
point in making their patients healthier so another plan can reap the
benefits 10 or 20 years later.

Other doctors say many HMOs' fee structures discourage preventive
care. "Its in the contract that you must provide this," said Dr. Brian
Greenberg of Tarzana, who has many HMO patients. "But there is no real
[financial] incentive."

To provide a year's care to a 1-year-old, Greenberg says, he receives
fees of $266 to $377 from various HMO-related medical groups with
which he contracts.

His wholesale cost for immunizations for children in the first year,
however, comes to $220--leaving him as little as $46 to provide all
other care a child might need.

Given the scant incentives to provide care, "for a practice that is
less scrupulous, there are lots of places where skimping can occur,"
Greenberg notes such as delaying vaccinations. "If you have a practice
like ours, committed to providing the best care you can, you're still
going to feel rushed or pressed when you're seeing children in these
circumstances."

[A Mixed Diagnosis for HMOs, Michael Hiltzik and David Olmos, Los
Angeles Times, August 27, 1995]

     Brought to you as a public service by ABLEnews. A
     Fidonet-backbone echo featuring disability/medical       
     news and information, ABLEnews is carried by more than       
     500 BBSs in the  US, Canada, Australia, Great Britain,     
     Greece, New Zealand, and Sweden. Available from Fidonet      
     and Planet Connect, ABLEnews is gated to the ADANet,       
     FamilyNet, and World Message Exchange networks.      
     (Additional gating welcome on request.) The echo may be
     reached via telnet at <http://www.icdi.wvu.ed>.
                                     
     ABLEnews text files (suitable for bulletin use) are
     disseminated via the ABLEFile Distribution Network,
     available from the filebone, Planet Connect, and
     ftp.icdi.wvu.edu.

...For further information, contact CURE, 812 Stephen St., Berkeley
Springs, WV 25411. 304-258-LIFE/258-5433 (CUREltd@ix.netcom.com)






 


