When Care is Denied : Bureaucracy and cost controls are the culprits that Californians typically blame when HMOs deny them medical care. Here is one patient’s story: : DEANNA GLICK / A Diabetic’s Dilemma
If you feel stuck with an HMO that doesn’t suit you, you’re not alone.
Many people can’t switch plans because they can’t afford it, or their employers offer only one. Lack of choice is especially troublesome for those with chronic conditions.
Consider 23-year-old Deanna Glick, an associate editor of Veterinary Product News in Irvine.
Glick, who has diabetes, knows that closely managing her blood-sugar level can help prevent blindness, kidney disease and other complications of her condition. And she dreams of keeping herself healthy enough to have a child someday. She proudly describes how, until she joined an HMO last year, she followed a preventive regimen, recommended by experts, involving exercise, diet and blood-sugar checks four times a day.
“A lot of diabetics don’t watch their diet the way I do, don’t exercise as often as I do and don’t test their blood as often as I do,” says Glick, who lives in Fullerton. “My doctors were always amazed at how well I took care of myself.”
But that was while she was covered on her father’s insurance plan, which paid 80% of her preventive care. After starting her job last year (at a $20,000 salary), she chose the cheaper of the two health care plans offered by Fancy Publications Inc., which owns Veterinary Product News. Figuring she couldn’t afford the $151 monthly premium for a preferred provider plan through CareAmerica, she opted instead for a no-premium CareAmerica HMO plan.
Once enrolled, Glick discovered the HMO doesn’t cover items she needs to manage her blood sugar, including lancets for pricking her finger, blood-test strips, alcohol swabs and syringes. These items run her about $1,200 a year.
On a tight budget, Glick says she cut her blood-sugar tests to twice a day. She began relying on occasional care packages of supplies from her parents and boyfriend.
Glick blames CareAmerica. “This disease is something that’s controllable, but they are taking that privilege away from me,” she says.
Dr. Arthur Southam, chief executive of CareAmerica Health Plans, says the company provides all benefits that the state of California requires. He suggests Glick try to get a law passed that would mandate the sort of coverage she wants.
Glick protested the exclusion, then attended a grievance meeting July 28 with officials at the insurer’s administrative office in Woodland Hills. Armed with research results, she argued that if CareAmerica covered her supplies for preventive care, the insurer might avoid paying for costly emergency room visits down the road.
But CareAmerica’s medical director, Dr. James Reilly, disagreed. “When we don’t cover supplies, it’s not the expectations of our prescribing physicians or CareAmerica that that means people won’t be checking for sugars,” he said. “It’s just that we think people will be providing that themselves.”
It’s up to employers to pay for such benefits.
Reilly noted that CareAmerica offers a medical plan with a higher premium that covers diabetic supplies--but only three employers have opted for it.
“Employers just have not had any interest, or rarely any interest, in paying that extra premium which would cover the diabetic supplies,” he said.
Barbara Kotowitz, Fancy Publications’ human resources director, says the company is satisfied with CareAmerica’s coverage and doesn’t intend to switch to the more expensive plan.
Glick, still waiting for results of the grievance meeting, doubts she persuaded CareAmerica to change its policy. But she says she won’t give up--and may request another chance to make her case.
