When It Comes To Crappy, HMO-Based Healthcare, Joy Atkins Has Already Paid Full Price.
by Karen Brandel
JOY ATKINS WAS like many of those who responded to a recent Gallop poll on healthcare--she was happy with her HMO, known as Partners Healthplan of Arizona. Then she got sick. She never dreamed she'd become mired in a complex lawsuit against Partners, and was stunned to learn that many people in her position--totally disabled due to substandard care--are unable to sue an HMO for malpractice.
When Atkins began having severe headaches, she went to the primary physician Partners had assigned her. Based on her symptoms, the physician ordered a CT scan of Atkins' brain. Partners denied the costly scan, but the doctor re-requested it--a bold move according to several physicians who say their experience has been that HMOs sever contracts when physicians request costly procedures, thereby cutting off a large part of the doctors' incomes.
After Atkins collapsed and lost consciousness at work, her doctor requested the scan a third time, because Partners had once again denied it. It was too late by then: Atkins had an aneurysm in her brain. Sadly, a CT scan could've picked that up before the aneurysm ruptured.
The bleeding into Atkins' brain caused permanent damage, leaving the once-healthy 45-year-old legally blind and wheelchair-bound. Much of her memory is gone, her speech is slurred, and she suffers seizures.
If anything was fortunate in that tragic series of events, it was Atkins' decision, before the stroke, to quit her job at El Dorado Hospital in favor of another position elsewhere. That left her paying her full premium to Partners without her employer paying any portion of it. Oddly, that fact subsequently left Partners without ERISA (the Employee Retirement Income Security Act) to shield them from a major lawsuit.
When ERISA was drafted in 1974, its intent was to protect employees' pensions and benefits. HMOs are quick to use it when threatened by a lawsuit, claiming the health plan was governed by ERISA. That moves everything into the federal arena; and under federal law, a person can only sue for the cost of the procedure which was denied, such as a $300-dollar CT scan, but not for damages or negligence.
In Atkins' case, attorneys for Partners cried ERISA when her friends retained Tucson attorney Gary Grynkowich to file, on her behalf, for damages, negligence, breach of contract, and practicing medicine without a license.
When it looked like ERISA might not apply in her case, Partners pointed at the physician they had assigned Atkins, who ordered the scan three times. Now they say she had not advocated strongly enough for her patient.
Thousands of cases like Atkins' trudged their way to the courts in the late '80s and early '90s, only to be quashed under ERISA. Although it saved them substantial costs, these cases were not exactly searing moral victories for the healthcare plans.
Comments Grynkowich, "If you read some of these decisions, you find yourself thinking, 'Wait a minute, this isn't America.' No one is held accountable. These companies never had to pay for their screw-ups, so what's to stop them from denying medical care?"
Like many other states, Arizona has introduced bills to regulate HMOs in an effort to protect those enrolled in the plans. But what our state legislators don't seem to realize is their laws are useless against most HMOs, because most are part of employee-benefit plans and thereby shielded by federal law.
Grynkowich is hopeful the courts will slowly unravel the snag in the federal ERISA law that allows HMOs off the hook when they place financial considerations over medical ones. He sees hopeful changes already: "At present, the law states that if, at the time you file your lawsuit, you're not in an ERISA plan, then state common law rights can apply. But it comes down to you're going to have to quit your job so you can pursue a lawsuit."
Even if you suffer permanent damage but are still able to work, this is the only way around it. Because attorneys for Partners filed appeals, Atkins' case may take years to resolve. Adds Grynkowich: "I hope people are realizing that these HMOs are great--as long as you don't get sick. The so-called care is affordable, but it's not available."
'A Duty To Die'
Former Colorado Gov. Richard Lamm Says Old People Must Stop Hogging Increasingly Expensive Healthcare.
DOCTORS' UNIONS--OF the type physicians at Tucson's Thomas Davis Clinic are forming to deal with their HMO overloads (See "Too Many Beds," right)--simply won't work, according to Richard Lamm, a former governor of Colorado turned healthcare reformer.
"Economic history persuades me to say that prices are driven down when there's an oversupply, and there are far too many doctors, far too many specialists," Lamm says. "If Tucson doctors think a union will help, they better look around the nation. Incredible dislocations in health professions are taking place. Even the status quo is no longer an option."
Lamm just finished his term as chairman of the prestigious Pew Health Professions Commission. Although it has no regulatory power, The Pew Commission has a great deal of political influence and an enormous amount of money behind it, namely the Pew Charitable Trusts, a Philadelphia-based philanthropic organization.
One of the Commission's 10 proposals includes the startling recommendation to make each of the nation's 10.5 million healthcare workers a jack of all trades, since it would cost a lot less.
But Fran Roberts, of the Arizona Hospital and Healthcare Association, claims such proposals are already unfolding in the workplace--a prime example, she says, is the increasing use of unlicensed workers.
"We need to stop cranking out doctors and nurses," she says, "because we're just preparing these people for a healthcare world that no longer exists and for jobs that aren't there. Managed care demands that the same services be done for less money, so there will be a loss of jobs. But if it's a better and safe way to operate, so be it."
She points to psychologists as a prime example: "We now have a new healthcare worker--a psychiatric nurse practitioner. This worker can prescribe and dispense medicine, assuming a major function of a psychiatrist, for less money. Since psychologists can't prescribe drugs, where will they fit in?"
But Roberts is leery of Lamm and his more personal ideas for curbing healthcare costs. Although Lamm is deeply involved in some of the most influential health policy groups in the nation, he still maintains his most provocative view--the need for a gradual move toward rationing healthcare and technology for the elderly.
His remark, way back in 1984, that "the elderly have a duty to die," stirred a controversy which, oddly, propelled him to higher echelons within health policy groups.
Lamm advocates age-based rationing of healthcare as a way to curb costs, because he views the aging of the population as the principal cause for those increased costs. He also wants an end to any more age-based benefit programs. Says Lamm, "Of course we have more of a duty to a 10-year-old than to a 60-year-old. Common sense says we should reserve the expensive medicines and technology for those who have the chance of a longer life."
Counters Roberts: "This kind of thing is real scary to me. The danger is that ideas like this are getting a lot of attention in Congress. Say we implement new criteria, such as at age 75 you'll only receive comfort care. So if you get pneumonia, you'll get something to make you feel better, but not the antibiotics to fight the infection that can kill you. Don't kid yourself, that's what's really behind these ideas. You can even make it sound compelling by getting some old people to say they don't want to take care away from their grandchildren. That just devalues an entire generation of people."
Lamm points out that medicine is already rationed by leaving people out of the system. "Forty million people don't have health insurance, so nobody's going to tell me we're not already rationing care."
(Arizona is comparable with the rest of the nation, with 15 percent of its population without any form of health insurance, according to an exhaustive study compiled by a national survey research firm. Where Arizona sadly stands out is that, of its 150,000 uninsured children, nearly 95 percent live in households with an employed main wage earner who often works two or more jobs.)
Lamm concedes that rationing care on the basis of life expectancy is a tough issue to tackle. But he adds, "We can't afford to do everything for our aging bodies, any more than we can afford to expect police protection to include installing burglar alarms for everybody."
He's concerned about the huge number of people--the baby boomers--who'll fall ill and enter the healthcare system with high expectations. "I don't want to be the one who has to choose whether it's my father or my daughter who receives the expensive care. Individuals shouldn't have to make those terrible, Sophie's Choice decisions. But cost- containment programs will force people to grapple with it, because healthcare is bankrupting us. We spend more than $3 billion a day on healthcare, and it can't go on like this. It's reality time."
Too Many Beds, Too Many DoctorsHow HMOs Exploit The System To Create Maximum Profits While Encouraging Lousy Care.
THE BASIC, BARE-bones structure of corporate healthcare in America: Most doctors belong to group practices, most hospitals belong to multi-hospital systems, and HMOs have largely replaced conventional, indemnity health insurance. The threads connecting these three entities are contracts of every kind imaginable. The contracts are dictated by the HMOs, and that makes for some very ragged edges.
Of the nine active HMOs in Tucson, nearly all have been, or are in the process of being, gobbled up by even larger companies, according to the Arizona Department of Insurance. That will eventually leave a few very big players with even more clout.
That HMOs use the federal Employee Retirement Income Security Act (ERISA) against their own patients is distressing (See "The Human Cost," above). But the presence of these companies has distorted the healthcare world in other ways as well--ways that are not entirely their fault.
The HMOs all look good on paper. They're highly profitable; but most importantly, nearly all the HMOs in Tucson spend about 82 percent of their premium dollar toward healthcare. Only 10 to 15 percent goes toward administrative costs, which is certainly not exorbitant.
What may be the source of so many problems is that Tucson, like the rest of the nation, has too many hospital beds and too many doctors. HMOs, in the spirit of free enterprise, play each hospital against the others and each physician group against the others.
Most hospitals, even if they've merged with larger hospital chains, are fighting to survive by wringing out all the costs they can. As part of the squeeze, they've laid off many registered nurses and hired people without medical educations to perform the so-called dirty work (See "Bedpandemonium," below).
Physicians receive extra cash if they've been able to keep people out of the hospital, but if they've exceeded the HMO's projections for hospitalization, they actually lose money.
"It gets to the point where hospitals and doctors can't accept any less money. They'd rather not have the business than be losing money on every single patient the plan sends them," says Allen Charlesworth, vice president of finance for the Arizona Hospital and Healthcare Association. "That situation hasn't hit here yet, but it's coming, and it's not that far away. I see it because everybody's gearing up for the next round of negotiations, and the HMOs are continuing to demand lower and lower rates. Hospitals and doctors are reacting by reasoning that if they can make a profit and steal somebody else's business, they give in to the lower rate."
Meanwhile, economists argue about whether the true cost of healthcare has even gone down under managed care. The cost of an average hospital stay has certainly plummeted, but way over on the other end, it's healthcare dollars that are used to pay for stock options--to the tune of $23 million a pop and more--of the same money spent for huge executive bonuses for closing deals.
"Yes, that money is part of the expense of healthcare, so there are situations where administrative costs may be unreasonably out of line," concedes Donald Shropshire, president emeritus of Tucson Medical Center. "But the market is the only thing paying attention to that. If I were the chief executive officer of a for-profit managed care plan and I saw the opportunity to come away with $16 million for the sale of that because they're having to pay for the stock I own, I might be tempted to sell it--even though it may not be best for the patients. The incentive is there to continue that course of action, which is unfortunate.
"In healthcare today," Shropshire says, "you have directors who have a prime allegiance to the stockholder. We don't have a satisfactory answer to this yet."
Verne Singleton, former CEO of University Medical Center, says "managed care is a good idea that's going bad. Should our healthcare be managed based on the value of our stock? It's become a commodity because the world revolves around economics, like it or not."
There are plenty who don't like it. Physicians are much more vocal, and some--like those at Tucson's Thomas-Davis Clinic--are in the process of unionizing. According to Dr. Robert Osborne, who's spearheading the efforts to unionize the Thomas-Davis physicians:
"The HMOs offer a physician group an exclusive contract to take care of a large volume of patients. What happens is that another physician group, alarmed at losing patients, scrambles together and offers to do it for less. When it comes time to renew the contract, the HMO claims their costs have been too high--the physicians will have to take a 10 percent reduction or lose their patients to another group. But it takes some expense to be able to give quality care."
There are so many groups of physicians competing for the same base of patients that, for the first time in U.S. history, physicians see medical unemployment as a looming threat.
"I don't think the public is at all aware of what's really going on and the extent of this," says Osborne. "Physicians used to simply pull their patients out of those conditions and admit them elsewhere, but now we have no say in this because HMOs tell us where to admit patients. If we complain, we'll be de-selected by the HMO. We can't demand the hospital change, because it's busy trying to survive."
Osborne believes the only way to give physicians a say in how their patients are cared for is to unionize.
The American Medical Association won't rally behind him because so many of its members are part of the management or ownership of HMOs. Osborne even challenges HMOs' often-claimed success in preventing illness: "It's farcical. If you have an acute heart attack, managed care will take care of you, because if they didn't, the public would be clamoring. But if you have osteoporosis, arthritis, chronic skin problems or chronic depression, the so-called care is lousy."
Physicians are also frustrated at the poor quality of care they're giving under HMO restraints, according to Osborne and six other physicians who requested anonymity.
"If you refer to a specialist too often, first it starts coming out of your own pocket, but then you're de-selected, which means you lose a lot of your business," explains Osborne. "But nobody can say anything because they'll be de-selected!"
Osborne believes that when HMOs started clamping down on referrals to specialists, the profits soared. "Greed is acceptable in America, but can it be mixed with healthcare? No, and therein lies the dilemma."
NURSES HAVE BEEN hit particularly hard by changes in the healthcare system.
These days they're quick to tell horror stories about their hospitals. Every nurse we interviewed was frightened at the prospect of ever being a patient in his or her own hospital.
They talk about impossible workloads as well as supervising the unlicensed workers who are increasingly assigned what were once nurses' duties. Some nurses are dismayed that their hospital administration asks them to consider what additional duties could be assigned to unlicensed workers--in other words, tell us how to give the heave-ho to more of your colleagues.
According to Fran Roberts, vice president of Professional Services at the Arizona Hospital and Healthcare Association, "It's kind of like the healthcare worker food chain. Scopes of practice are changing. Some of the work that only a doctor was previously allowed to do is now performed by Nurse Practitioners. Registered nurses are doing what only Nurse Practitioners used to do. Care keeps getting pushed down to the least-costly worker."
And hospitals continue to fire nurses while hiring people without medical educations. After eight weeks of hospital training, these newcomers are suddenly drawing blood, inserting tubes, and changing wound dressings--tasks formerly reserved for those who are licensed and regulated by an oversight board.
According to one cancer specialist, who requested anonymity, "These people could be tending bar one week, and several weeks later, they're changing the dressings on women who've undergone mastectomies. They don't know how to recognize the subtle signs of wound infection. They might know something's wrong if it's very advanced, but that's too late in my book."
But both nurses and unlicensed technicians complain about the effects of cost-cutting at the bedside.
In one recent instance locally, transporters brought a patient back from radiology without notifying his nurse that he was back in bed. About four hours later, the nurse finally had time to check on him, but found he had died.
"The horror is that people can die alone, and that people who shouldn't have died can die in an institution that once excelled in anticipating their every need," says a nurse employed at that hospital.
The hospital's answer was not to increase the number of nurses, nor even the number of unlicensed technicians, but to fire two nurses it claims should have made resuscitative efforts on the patient, who had obviously been dead for hours.
Other nurses point out that the people in the hospital are usually very ill or their HMO wouldn't have them there.
"We end up getting angry at patients and their families because we're always rushing to a crisis. On the way down the hall, a patient's wife asks me for a blanket for her husband, and I snap at her because I'm trying to do something about the patient who's bleeding out. But is it really too much to ask for? A blanket for a patient in bed who's cold? I can't believe the public puts up with this."
According to two nurses employed at a large local hospital, "If patients need help getting to the bathroom, we put them in adult diapers. We find them wet and in a lot of pain. We just couldn't get to them sooner."
Says one nurse sadly, "I feel terrible about this. I try to tell people they should never leave a loved one alone in a hospital."
Another nurse, who works in ambulatory surgery, where the patients go home the same day, complains her orders are to get the patients out as quickly as possible. "As soon as they open their eyes--just barely coming out of general anesthesia--we're told to stick them in a wheelchair and send them out. One woman's husband called because when he got her home, he couldn't arouse her enough to get her out of the car!"
Several nurses claim they can go an entire shift--12 hours--without having the chance to see some of their patients because they can be so tied up with a few very sick ones. Explains one: "It's not just that the quality of care for the patients is bad--it's terrible and unacceptable. And it's not just that there's unlicensed workers at the bedside rather than a registered nurse. There's no one at the bedside anymore!"
Some hospitals have programs to help their employees cope with the stress. One nurse, distraught by what she describes as the chaotic, unsafe conditions, finally called employee assistance from her ward--and heard a recording instructing her to call 911.
Healthy DisregardA CIGNA EMPLOYEE observes that many employers offer health plans to their administrative staff that are better than those they offer to rank-and-file workers:
"The administrative staff often has an indemnity plan, because if your kid gets sick, you want to go to the Mayo Clinic and have every test imaginable done for that kid." The rank-and-file workers are offered a choice of two or three HMOs.
Why would a CIGNA employee find this practice unfair? "Because, I mean, if people really knew about it--the restrictions and all--they wouldn't want an HMO."
Photos by Sean Justice, Gary Grynkowich, Donald Shropshire
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