By Albert Samaha
By Amanda Dingyuan
By Anna Merlan
By Anna Merlan
By Albert Samaha
By Tessa Stuart
By Anna Merlan
By Roy Edroso
Adding insult to injury is the fact that the people making these potentially life-altering medical decisions are often not our doctors but the infamous gatekeepers, whose job it is to make sure that money isn't being wasted. Ironically, the very fact that such gatekeepers are not doctors makes them exempt from legal liability for the medical decisions they do make. So, while an HMO may have decision-making power over, say, whether you should have a certain surgery or test, those HMOs often cannot be sued if you are harmed or even die as a result of their decisions.
Such is the state of patient rights at this strange moment in our health care history, when the law has yet to catch up with current practice. Long-standing federal legislation shields most employer-sponsored health plans from such liability. And in New York State, the public health law goes even further, saying that ''health services provided through HMOs either directly or indirectly are not to be considered the practice of the profession of medicine.'' So the few lawsuits that are allowed against HMOs at this point can make claims only for the cost whatever treatment was denied and not for damages.
The injustice of having little or no legal recourse to address the behavior of managed-care companies seems clear, which is not to say that the legal loopholes will be addressed anytime soon. Even though politicians of both stripes seem happy to criticize HMOs and give lip service to patient rights, legislators are divided on how--and whether--to remedy the system's more egregious flaws. The bills proposed by the regulation-hating Republican leadership wouldn't guarantee patients the right to sue their managed-care companies (the cornerstone of the Democrats' Patients' Bill of Rights Act), nor do they make other reforms proposed by the most widely supported Democratic bill, including requiring health plans to pay for visits to out-of-network specialists, ensuring access to all prescription drugs, and prohibiting managed-care companies from giving financial incentives to doctors who cut corners on care.
Patients, doctors, and trial lawyers have rallied behind the more rigorous (Democratic) plan to rein in managed care. But even this odd coalition of HMO critics is little match for its opponents--including insurance companies, some large corporations, and the pharmaceutical industry. These are the same forces that brought the Clinton health care plan crashing down, and they no doubt have the power to forestall and weaken the current efforts. That is, of course, only if and when Congress actually gets around to having serious discussion of the various proposals, which have been on hold as our representatives tend to the matters of perjury and blowjobs.
Whichever way the political winds blow, our ailing health care system seems to show little sign of miraculous recovery in the near future. In the meantime, the Voice has decided to provide ongoing, humane coverage of all those struggling to make sense of our current confused way of health care. HMO Watch, a column that debuts this week, will monitor the trials, tribulations--and occasional joys--of real patients. We'll sort through the minuscule print of our tome-like contracts, listen in on some of those infuriating phone calls (for quality-assurance purposes only, of course), and generally track the ingenuity, insight, even humor, of the little people confronting the daunting intricacies of modern health care.
Raymond R. is thorough by nature. ''I'm a cataloguer,'' says Raymond, who's 53 but thinks he looks much younger. ''I love to organize things.'' So when his health insurance was running out this past summer, he made it his mission to comb through the stubbornly impenetrable details of managed care and figure out which plan was best for him. This, it turns out, was no small job.
Raymond, a former executive assistant, had qualified for permanent disability benefits--and the medicare coverage that comes with them. Among other things, he has HIV and a form of epilepsy that gives him frequent seizures. But he knew he also needed to belong to an HMO, if only to get coverage for the 11 medications he takes daily, which medicare doesn't pay for.
Raymond began by asking the surgeon he was consulting about a chronic back condition which HMOs the doctor belonged to, and then set out to comparison shop between those plans, which turned out to be Blue Choice and PHS. Rather than just scanning the gobbledygook in the plans' contracts for snippets of meaning, signing up, and taking his chances (as most of us do), or hiring a lawyer to wade through the legalese (as virtually no one does), Raymond decided to attempt the impossible: to make sense of the HMO contracts on his own.
''I cut the books apart, made xeroxes, and cut-and-pasted,'' says Raymond, a perfectionist who says he has an aptitude for visual arts. He took the numerous addendums--more than 50, he says, in the case of the PHS contract--cut them from a separate booklet and literally pasted them into the paragraphs in the body of the contract where what they talked about was actually addressed. So, for instance, if there was an exclusion listed in the addendum, he cut it out and spliced it in the main section on exclusions so he could see the entire list of what plans don't cover and clearly compare the plans. After several days of having his apartment covered in xeroxes, glue, and paper scraps, Raymond ended up with ''a giant roll of paper like the Dead Sea scrolls.''