The patient vs. the cold world of managed care

Staying Ahead

February 10, 1997|By Jane Bryant Quinn | Jane Bryant Quinn,Washington Post Writers Group

WHAT HAPPENS when your medical plan refuses to give you the care you believe you need? There's an appeals procedure. But it isn't much good if you're in mortal danger or serious pain, or you're being thrown out of the hospital just a few hours after major surgery. Welcome to the new world of medical rationing.

It's going to get worse as health costs rise and employers fight to hold down their health-care expenses. But patients have ways of fighting back. In their anger and fear, they're creating a new political movement: a consumer crusade for patients' rights.

Tens of thousands of patients and their relatives have called, written, faxed and e-mailed their legislators, protesting against what they see as heartless medical care. Almost every state has recently passed at least one law reversing the new cutbacks in treatment.

The managed-care companies argue that government has no business interfering with the sacred insurer-patient relationship. (The relationship used to be doctor-patient. If it were still, this column wouldn't be written.)

HMOs have a point when they say that the legislatures shouldn't be micromanaging medical care. Nevertheless, laws get passed when managed-care plans go too far. From the patients' point of view, they're up against a monopoly because they're stuck in plans their employers choose. States have an interest in any monopoly.

Here are some of the seething consumer questions that the states have addressed so far, according to the Health Policy Tracking Service (HPTS) of the National Conference of State Legislatures in Washington:

Which doctor should you call? Normally, you have to start with a primary-care physician. To see a specialist under the plan, you need his or her permission.

Gynecologists are specialists. But a majority of women consider them their primary doctors, according to a 1993 Gallup Poll. In 20 states the law now allows women in managed-care plans to see gynecologists and obstetricians without another doctor's permission.

When are emergencies paid for? HMOs normally don't cover unauthorized treatment in nonmember hospitals. They'll pay if there's an emergency. But with perfect hindsight, they may decide there was no emergency. That pain in your chest turned out to be indigestion, not a heart attack. You have to pay the emergency-room bill.

In 17 states, HMOs now have to pay for emergency treatment at nonmember hospitals, if a prudent person might think that a real danger existed.

Who can you trust? Some managed-care plans order doctors not to tell patients about alternative treatments (some of them costly) or whether the doctor has a financial incentive not to treat. They also aren't supposed to discuss competing plans. Gag rules like these are now illegal in 20 states. Health plans aren't supposed to retaliate against doctors who talk. But a plan can come up with many reasons for firing a doctor, so it's hard to know how well anti-gag laws really work.

Will you be offered a last chance at life? Only a handful of states require managed-care plans to allow bone-marrow transplants for women with advanced breast cancer. Many plans pay voluntarily, but you can't count on it.

Will your health plan stabilize your newborn? Some new mothers and babies have had to leave the hospital in as few as 12 hours after birth, with 24 hours becoming the standard.

Some babies manage; others run into trouble; a few die of problems that a hospital would have caught. Longer maternity stays are now required in 29 states, including Maryland. Next year, federal law will require a stay of up to 48 hours for normal births and 96 hours for Caesareans.

Can you stay in the hospital after a mastectomy? "That's this year's big issue," says the HPTS' policy specialist Molly Stauffer.

Mastectomies aren't hopscotch. But some HMOs don't let patients stay in the hospital overnight. They go home and rely on relatives to tend the wound.

Thanks to female fury, 15 states have introduced bills requiring inpatient stays for mastectomy patients. New Jersey may become the first state to get such a bill through the legislature.

Even the American Association of Health Plans, the trade association for managed care, has come out in favor of letting women stay in the hospital if they want to.

You'll notice that only politically powerful groups are getting rationing reversed. That's no way to run a medical system.

But neither is it smart to put public health in the hands of insurers who only want to get their profits and bonuses up.

Pub Date: 2/10/97

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