HMO Revolution in California

After knowing virtually nothing about the HMO stranglehold in California, I thank you for the series of articles by Michael Hiltzik and David Olmos (Aug. 27-31).

I have been to “the medical mountaintop,” when my first child was born with a rare metabolic disease. Blue Cross allowed us to seek the best advice and treatment for her, virtually anywhere in the United States; and today, this child, whom we were told would not live to see her second birthday, is a 1995 college graduate and starting her career as a teacher in Palo Alto this fall.

Now, here’s the rub. Her new employer offers three HMO plans for medical coverage. After speaking to each of them and to several other arbitrarily chosen HMO plans in California, each HMO supervisor told me to find more conventional insurance for my daughter. To a one, they agreed their HMO couldn’t guarantee her the continued care she needs from the experts in Boston she regularly visits. The thought of putting her life into the hands of people who might say, “Why spend so much money on experimental procedures when she’s going to die anyway,” is as infuriating as it is frightening, callous and ignorant.

I will help my daughter pay the premiums on a policy that will offer her complete medical coverage but the real insurance comes from knowing she’ll be cared for by doctors whose only concern is her welfare, quality of life and ultimate longevity.

CANDACE KRAFT GEGENBERG

Beverly Hills

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* “A Mixed Diagnosis for HMOs,” Aug. 27:

As one of the 92% reported in The Times as satisfied with my HMO, after almost 40 years with Kaiser Permanente, I want to state that I have never lacked any care or testing through kidney disease, dialysis, heart attack and a kidney transplant with the necessary care afterward. Kaiser provided flawlessly all these years for every medical need. If I had been left with any other health care provider, I would not have received such care.

I have retired two excellent doctors and have seldom met any employee who was not only competent but cheerful, helpful, etc. Compare that with the bumpy road traveled by those who think their choice for care is superior.

GEORGE W. GOSSER

Thousand Oaks

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* It’s unfortunate that despite ample evidence--provided by your own survey and many others--that 92% of those enrolled in prepaid care are happy with their health care, your lengthy series of stories essentially chose to focus on the minority. Your stories do little more than revisit the timeworn argument that managed care is typified by mediocre medicine and financial gatekeepers more concerned with turning a profit than providing sensitive, quality patient care.

With some 50 million people nationwide enrolled in some form of managed care, it becomes increasingly important to understand that HMOs vary widely in ownership, organization and motivation as well as in the design and quality of the services delivered. The fastest growing sector is for-profit, stock-exchange-traded companies with shareholders who expect returns on their investments--an important consideration that your series largely ignores.

As a not-for-profit organization, Kaiser Permanente’s philosophy is one of health care, not bottom line. Our goal has always been and continues to be to provide timely, appropriate medical care. This is also the most cost-effective care. Withholding or denying care in order to save money, as your series alleges, makes absolutely no sense--medically, economically or ethically. It never has and it never will.

The idea of the physician “gatekeeper” is as abhorrent to Permanente physicians today as it was in 1955 when physicians in Henry Kaiser’s fledgling health plan broke loose and formed their own corporate entity, the Southern California Permanente Medical Group. Its purpose then was to ensure the independence of physicians in making medical decisions free of interference and in the patient’s best interest. This approach still serves as the model for Kaiser Permanente’s operating structure.

Because your articles make little distinction between for-profit and nonprofit HMOs, and between network and group model HMOs, we believe you have misinformed and confused your readers.

There’s a perception that when competitive economics push down expenditures, quality is somehow at risk. However, controlling costs also means allocating resources efficiently and learning, as everyone in the health care industry must do today, to do more with less. Since prevention, early diagnosis and treatment and scientifically informed clinical decisions frequently result in the most effective interventions, improving quality often translates to lower costs.

Kaiser Permanente is no stranger to criticism. Years ago, we fought opposition from the American Medical Assn., which viewed our prepaid medical care as a form of socialized medicine. Having stood the tests of time and misunderstanding, today we see a proliferation of competing plans, many of them modeled on our approach.

OLIVER GOLDSMITH MD

Medical Director, Southern

California Permanente Medical Group

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* We have enjoyed the series of articles about HMOs. The Aug. 27 article, however, contained one factual error and one striking irony.

In an attempt to demonstrate that most patients are satisfied with their care, the authors reported the story of Sandy Beck, a CareAmerica subscriber. He actually had parotid surgery, followed by 34 radiation treatments (not thyroid surgery and chemotherapy). We were his surgeons, and provided his care through our contract with Lakeside Medical Group, an individual practice association. CareAmerica looked good.

The irony is that just last month, Lakeside Medical Group chose to fire us (after six years) and contract with other specialists to provide ear, nose and throat care for their patients. The decision was strictly a financial one. We could not afford to provide the same type of care with which Beck was so pleased, at the new lower rate. We hope the new specialists can.

Unfortunately, health care has become a big business with more and more groups profiting from the doctor-patient relationship. What is forgotten is that doctors and patients are not commodities that should be sold to the low bidder.

DAVID J. AROESTY MD

WARREN S. LINE JR. MD

North Hollywood

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* Your survey finding a 92% satisfaction rate among HMO enrollees would be reassuring to its members if more details such as the annual turnover rate are also included.

An enrollee from a large HMO consulted me several years ago for her “asthma,” which had failed to respond to all measures instituted by her HMO doctors. It was only after she suffered from a seizure from massive doses of cortisone and anti-asthma medications, yet without any relief, that she finally consulted me on her own. It turned out that her shortness of breath was not from asthma at all, but from a condition known as vocal cord dysfunction. In fact, some of her anti-asthma medications might actually have aggravated her problem instead. With the advantage of hindsight, I made this diagnosis in a single session after she had suffered from this condition for many years. Incidentally, she did pay my fees out of her own pocket, and this part of the hidden medical cost will never be uncovered in any economic survey on HMOs. On the other hand, I am also fully aware of unnecessary procedures done in the fee-for-service setting. In short, there is no one single answer to meet all of our health care needs. The most important criterion remains “a plan in need is a plan indeed.”

JOHN T. CHIU MD

Corona del Mar

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* “A Diabetic’s Dilemma” (Aug. 27) vividly pointed out the difficulty people with diabetes have getting their HMO to provide the supplies necessary for complication-preventing blood sugar control. It neglected to mention, however, that California makes a bad situation worse by being the only state to charge sales tax on diabetes test strips and lancets. Everyone who has diabetes or who has a diabetic family member or friend should immediately contact their state legislators to ask them to rectify this cruel and dangerous situation.

BARBARA TOOHEY

Van Nuys

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* Re “Are Executives at HMOs Paid Too Much Money?” Aug. 30:

So California’s HMOs earned profits of more than $1.13 billion. Salaries and stock options in the millions of dollars. All for the benefit of the executives rather than the HMO members and the doctors, nurses and hospitals that provide the care.

Contrast this with Los Angeles cutting medical services with the future consequence of thousands becoming sick and dying. We don’t have a health care crisis in this country, we have a greed crisis.

CRAIG S. BLANCHARD

Seal Beach

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* I can’t believe you’re complaining about the salaries health care executives make! Look at what automobile industry CEOs make. For that matter, look at pro athletes and movie stars.

We need the best and the brightest in charge of our health care, which is clearly a critical societal need. And, these positions need to be well compensated in order to attract first-rate talent.

KIRSTEN A. FISHER

Los Angeles

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* In an HMO the less patient contact you have the more you make! Receptionists and nurses, who have the most patient contact, make the least. Doctors who have minimal contact with patients make a moderate amount. The CEO who never heals anyone makes the most.

Think about it.

ROGER L. WINTER

Pasadena

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* Your series on HMOs reminds me that on March 29 you published a front-page story that Speaker Newt Gingrich had called for a congressional investigation of the managed-care industry in a speech to the American Medical Assn.

Gingrich said he was concerned about the “accumulation of power” by HMOs and hoped to have the investigation under way no later than May. It hasn’t happened yet.

Details of the Republicans’ bill to curb Medicare, which have been leaked to the press, indicate they want to privatize it by forcing wholesale numbers of Medicare patients into HMOs.

Medicare already is the largest purchaser of managed care in the country, turning over about $1.3 billion of government funds annually. If the Republican bill is passed that figure would rise to well over $12 billion a year to HMOs with very little oversight.

Before committing that much public money, wouldn’t it make more sense to have the congressional investigation of HMOs first? Or are we destined to revisit the S&L; debacle?

PHIL WILLON

Palos Verdes Peninsula