By Albert Samaha
By Amanda Dingyuan
By Anna Merlan
By Anna Merlan
By Albert Samaha
By Tessa Stuart
By Anna Merlan
By Roy Edroso
Back in the days before managed care, the doctor's bag was the preferred symbol of American medicine. (Or, for dress-up purposes, that mysterious reflector strapped to the forehead.) Today we've somehow gotten to the point where the phone mail system would better sum up the American health care experience. It's through the phone that most of the 85 percent of Americans who have some form of employer-sponsored managed care now make our increasingly complicated medical arrangements. And most of the time we're not talking to anyone, just punching in numbers at the behest of automated messages, obediently holding for ''patient-care representatives.''
The indignation that swells in the heart at such moments does much to explain the powerful populist outcry against managed care. Surely by now you've heard the campaign ads in which practically everyone running for office promises to take on HMOs. Democrat Peter Vallone vows to pass a patient-protection act if he's elected governor. Democratic Senate candidate Chuck Schumer says he's ''the cure to the HMO mess.'' And even
Schumer's opponent, Republican incumbent Alfonse D'Amato, has fashioned himself a managed-care reformer, though he's so far avoided saying exactly where he stands on current proposals to reform HMOs.
It may seem surprising that people feel deeply about a wonky policy issue, but not when you consider that health financing is ultimately about our bodies. HMO rage boils down to the sense--some would say knowledge--that the ''patient-care representatives'' who must now approve our every medical move don't really care about our torn ligaments, our allergic reactions, our miscarriages. This cuts deep. It's as if we're holding our boo-boos--both large and small--up for a kiss, but instead of mommy, or even the family doctor, we find only underpaid telephone workers trained to choose the cheapest Band-Aids.
So while we may tolerate a less than heartfelt ''have a nice day'' approach at our computerized banks and the hollow pleasantries printed on our receipts, the creeping conglomeration of the actual practice of medicine is quite another thing. Cheery-sounding names and plastic membership cards haven't fooled most patients, who report in survey after survey feeling less satisfied with managed care than with old-style coverage.
Corporate forces are nothing new in the health insurance world, of course. But while insurance companies might have squabbled over doctors' bills in the past, managed care now positions these corporate elements to have a say in the actual treatment of our very personal aches and pains. And that makes patients, doctors, lawyers--and almost anybody who's not making money off our new system--want to draw the line.
In fairness, managed care itself isn't to blame for our woes as much as the climate in which it's taking shape. Charging patients a flat fee for what is essentially a combination of insurance and medicine actually evolved as a way to remedy some of the injustices of our previous system, under which health expenses went through the roof. While the fee-for-service insurance that used to predominate has built-in incentives for doctors to schedule too many appointments and order too many tests (because the more they do, the more they get paid), the new arrangement is designed to keep costs down. At its best, managed care even pushes doctors to treat problems before they get out of hand--and more expensive to treat.
But the laudable goals of managed care haven't all played out as planned. Operating in a highly competitive market, companies find it hard to resist cutting corners. Some have actually come right out and given bonuses to doctors who keep costs down. It's this bottom-line orientation that's to blame for the most horrifying HMO tales: the upstate woman who died while her managed-care provider hemmed and hawed about the necessity of a liver transplant, the patient whose breast cancer went undetected--and spread--when her HMO botched the follow-up on her mammogram, the teenage boy who died of heart problems after his HMO failed to provide adequate access to heart specialists.
These extreme cases show how far managed care has come from its progressive ideals. While the first HMOs were largely not-for-profit, this is no longer the case. In New York, more than a third of managed-care companies are now for profit. And these days even the not-for-profit HMOs are ruled by the expectations of executives who make oodles off this ''cost-efficient'' health care.
The 15 highest-paid managed-care executives made an average of $5.1 million last year, not including stock options, which themselves can run into the millions. Stephen Wiggins, chairman and CEO of the notoriously problem-ridden Oxford Health Plans, took home more than $30 million--and that's not counting stock options. On top of such astronomic expenses, some managed-care companies have recently announced they're putting additional millions into ad campaigns to spruce up their sickly images.
Few managed-care companies are actually making money for their investors or keeping costs down--and some have even gotten out of the health care business entirely. Yet such expenditures and the backdrop of the high-rolling health care market (which went up before its current down) makes the penny-pinching ways of plans look especially bad. Consider, for instance, the stinginess of most HMOs in even the tiniest details, such as the mailing of basic information required by the law. (According to an investigation by public advocate Mark Green, HMOs in New York failed to provide required materials in response to requests 83 percent of the time.) But, of course, the most troubling failures of managed-care plans are not the small inconveniences, which may be annoying, but the real matters of care, which can add up to a major crisis for anyone who has a real health problem.
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.''
After scrutinizing the reconfigured contracts and making numerous phone calls to clear up his remaining confusions, Raymond decided PHS was a better bet for him because the people on the phone were slightly more accommodating. But when he asked PHS for the list of drugs the company covers, ''They said we don't have that available,'' he recalls. When the ever vigilant consumer mentioned that HMOs are required by law to make their drug formularies available, the company's representative promised to look into the issue. A few days later, the PHS staffer called to invite Raymond to come to their offices in the Chrysler Building and take a look at the company's drug formulary. ''This guy came out with a booklet and Post-it notes so that I could mark the pages that needed to be copied.''
In fact, PHS was adhering to the letter of New York State law, which requires that HMOs must ''allow prospective enrollees to inspect drug formularies.'' Nevertheless, Raymond was frustrated. ''He was nice enough, but this is no way to review a formulary.''
Despite the inconvenience, Raymond stuck with his choice of PHS (in part because the Blue Choice formulary, which they sent him readily, was more limited). But, as his new plan kicks in, the patient who has tried to foresee all complications is already running into new problems, particularly getting access to all the providers he's used to seeing. He had, not surprisingly, already checked to make sure his eye doctor--who had diagnosed him with an HIV-related condition that Raymond describes as feeling like there's ''a shifting polka-dotted cloudy film'' over his eyes--was included in the PHS plan. But when he went to see that doctor a few weeks ago, he learned he is no longer covered by the plan.
''I'll have to try to find a person who specializes in that who's in the plan,'' sighs the persistent patient, who seems to have developed an almost religious zeal for coping with life's obstacles. (For inspiration, he quotes what someone said about Nelson Mandela's source of strength: ''If you are deliberate in taking risks of a certain course of action, then nothing can shock you because you've already come to terms with the possibility.'')
Even the daily epileptic seizures don't stifle his obsession with getting the care he deserves. He describes these episodes as ''an inner focused state of consciousness--it looks like a junkie nodding out.'' He'll be writing lists or making notes and then the next thing he knows, his pen drops and there's a mark across the page. But he just picks it up, straightens his things, and keeps going.