Patients and Profits

March 05, 1995|By SARA ENGRAM

In any grand struggle, ''follow the money'' is useful advice. It won't crack every case, but it can offer some revealing clues.

The health-care cost debate is no exception. As the medical marketplace reforms itself with an eye toward cost-saving efficiencies, can we assume that the purpose of health care -- the well-being of patients -- remains a priority?

That question came up in Annapolis last week, in a legislative hearing for bills dealing with health-care reform -- specifically with HMOs and their ability to control the physicians their clients can see.

At least one of these bills fits the classic description of the ''any willing provider'' measures that would essentially gut the HMO market in Maryland by forcing HMOs to let any doctor provide services to its members for a set fee. That notion deserves to die and most surely will.

But another measure heard this week -- a significant modification of the ''any willing provider'' concept -- ought to get a much closer look. If nothing else, the bill known as the ''Patient Access Act'' could cast light on some unhealthy tendencies in the health-care debate.

In brief, the bill would allow HMO members to see a provider outside the network, if that doctor is willing to accept the same fee the HMO would pay its own doctors for that service. The HMO would pay 80 percent of the cost, while the patient would bear 20 percent. Any further out-of-network care would be subject to review by the HMO, which could deny payment.

That approach returns some measure of choice to patients -- if they are willing to pay for it -- while protecting the interests of the HMO. Yet the HMOs persist in labeling the approach as an unbridled threat, ''any willing provider'' in disguise.

Barbara Topper, a public-school music teacher in Dundalk and mother of two teen-agers, doesn't see it that way. Born in 1942, Ms. Topper was a ''blue baby.'' In 1949, she underwent the pioneering ''blue baby'' surgery at Hopkins and lived without further problems until the late 1960s, when she had extensive open-heart surgery.

In 1986 she moved to Baltimore and enrolled in an HMO after being assured that, should further heart problems arise, she could see her Hopkins specialist. For the next several years, she says, she, her husband and children were fully satisfied with the primary care they received.

Then, in 1992, she developed a heart irregularity. Her primary care physician and the network cardiologist agreed that she should see her physician at Hopkins, but they were overruled.

She was hospitalized under the HMO's care, but after a week the doctors had not been able to stabilize her condition. She checked herself out and, on her own, made an appointment at Hopkins. Within three days, her problem was under control and she was able to return home.

Barbara Topper is alive and well -- thanks to her own pocketbook and, she feels, despite the HMO's attitude that her health came at too high a price. She notes, too, that the HMO's refusal to let her visit an out-of-network specialist cost them money too -- a fruitless week in the hospital.

As HMO membership grows in Maryland, more stories like this one are beginning to surface. The anger of patients who feel that, when difficult problems arise, HMOs are more concerned with controlling costs than with curing their ills finds a natural outlet in bills like the ''Patient Access Act.''

The curious thing about the health-care debate is that patients -- the consumers of health care -- are not powerful voices because they don't control how the funds are spent. That usually falls to their employer, who decides which health-care package to purchase.

Those decisions are rightly made with an eye to costs which, if uncontrolled, can cripple a company. Even so, health care is an earned benefit, and patients have a huge stake in those decisions.

Could the right to opt out of an HMO network for a specific service -- a right that would cost patients more and that could be closely controlled by the HMO -- really wreck the concept of managed care? HMOs and their allies in business and labor are saying yes.

But the challenge legislators face is the old trick of following the money, and on this issue the HMOs have some explaining to do. How could this option cost them money if they, in fact, are liable for only 80 percent of the amount the service would cost them in-house -- and if they retain control over any further care?

It's worth noting that one of the hottest stocks in Maryland is Mid Atlantic Medical Services Inc. Curiously enough, as its pretax income rises, its medical expenses are falling by about the same percentage.

A clue? Enough of one to warrant better justifications of their opposition to the Patient Access Act than HMOs offered last week.

Sara Engram is editorial-page director of The Evening Sun.

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