Choices and Costs in Health Care
You should be commended for your recent excellent series on the health care crisis (Part I, April 23-25). I would, however, like to note some additional points:
1. Health maintenance organizations (HMOs) are suppose to cover all the patient’s health care needs. Indirect rationing seems to occur in delayed appointments and refusal to cover certain standard medical and surgical procedures (e.g., a man with impotence recently came to me for a referal to a urologist after being shuffled around for almost a year by his HMO, which ultimately refused to authorize treatment, telling him “you’re 63, wait another two years until you have Medicare and they will cover it”).
In my own practice almost 7% of my patients have coverage through HMOs. They are choosing (and paying) for private medical care instead of the “free” HMO care. Obviously, if they also have indemnity coverage, this results in cost shifting into indemnity plans which further increases premiums.
2. Until a recent U.S. Supreme Court decision (Pilot Life vs. Dedeaux), indemnity plans were obligated by the California Insurance Code to process claims in a fair manner consistent with the insurance contract. If an insurance company arbitrarily denied claims, financial penalties could be assessed. However, with the Supreme Court decision, insurance companies have no financial penalties should they arbitrarily deny claims so as to increase their bottom line. Since very few people have the financial and emotional wherewithal to file a lawsuit against an insurance company to pay a claim, many services that should be paid for by insurance companies are being paid for by the patients. This has been happening in markedly increased frequency in the last two years since the decision was handed down.
I don’t know how to solve the financial crisis which is gripping the health care field, but whatever the solution is it should ensure that when an individual has insurance or HMO coverage, that the plan covers the services that it states it will cover without the patient having to be sent home waiting for an appointment, or having to file a lawsuit to receive reimbursement.
MICHAEL D. MYERS, M.D.
Los Alamitos