Consumer Good : HMO Enlists Advocacy Group to Put Together Guide for Public
The HMO industry and consumer-advocacy groups don’t often see eye to eye in the great debate over managed care.
So PacifiCare Health Systems, one of the state’s largest health maintenance organizations, tried a different tack last year when it hired Consumer Action, a San Francisco-based advocacy group, to develop a guide to help consumers navigate their HMOs.
While other advocacy groups have been active in health-care issues, Consumer Action had little experience in medical matters. Its focus is in personal finance issues, acting as a watchdog on telephone and utility rates and banking and credit card fees.
But Consumer Action was a good match for Santa Ana-based PacifiCare in other ways: It had no demonstrated bias on managed-care issues, and it had years of experience developing free educational material for consumers--often paid for by business or industry groups.
A Consumer Action spokeswoman says the group insists on editorial independence and that its publications are not influenced by corporate funding.
“We think it’s refreshing to find a corporation willing to put its money where its mouth is,” says Linda Sherry, editorial director for Consumer Action. PacifiCare paid the group $24,000 to create, print and distribute the 16-page brochure titled: “It’s Your Health: How to Get the Most Out of Your HMO.”
The brochure recommends that HMO members be active, assertive and persistent in seeking health care from their plans. It offers advice on how to choose and interact with a primary-care doctor, how to know what benefits are covered and how to resolve disputes that arise with doctors or the health plan.
The brochure tells consumers how to file an appeal with an HMO, how to file a grievance with state regulators and how to get patient-advocacy groups involved.
“As a last resort, consider contacting a lawyer,” the brochure advises. “Sometimes just a letter from an attorney will result in action.”
While other consumer advocates applauded the idea of helping members better understand their HMOs’ inner workings, a few took exception to some information in the Consumer Action brochure.
“It puts a more positive blush on the entire HMO world than may actually be warranted,” says Jeanne Finberg, a senior staff attorney with Consumers Union’s West Coast office in San Francisco.
For example, the brochure does not discuss payment arrangements with doctors, which, critics say, often give doctors a financial incentive to under-treat patients by delaying or denying access to necessary tests or specialists.
“It’s important to inform consumers that there may be incentives not to refer,” Finberg said.
The Consumer Action brochure is available in five languages: English, Spanish, Chinese, Korean and Vietnamese. For more information, call (800) 929-1606.
Then, Relief Arrives
Last time in this space, there was a story about a Santa Barbara couple suing PacifiCare over what they claim was the denial of medical services for their 14-month-old son, Daniel, who was born with several congenital heart defects. Leonard and Dana Wallock claim they piled up debts of more than $20,000 when their PacifiCare medical group denied home nursing care that Daniel’s doctors said he needed.
PacifiCare executives contend that the services were unauthorized and not a covered benefit under the Wallocks’ insurance policy.
A week after the story ran, however, a messenger arrived at the Wallocks’ home with a check from PacifiCare for $20,370.85.
“We are making this payment as a demonstration of our goodwill and to help relieve you of the financial obligation you have incurred,” PacifiCare Medical Director Csaba Mera said in a June 20 letter to the Wallocks.
“There are no conditions attached to this payment,” Mera’s letter said. PacifiCare, he added, will continue to “vigorously” defend against the “false and outrageous” claims in the lawsuit.
Mark Hiepler, an Oxnard lawyer representing the Wallocks, called it “simple posturing to try to make themselves look better.”
But PacifiCare spokesman Ben Singer says the payment was unrelated to the lawsuit or publicity.
“This was just the right thing to do,” he says, adding that PacifiCare has paid $375,000 in medical services for Daniel Wallock since his birth.
Times staff writer David R. Olmos can be reached by e-mail at david.olmos@latimes.com or by fax at (213) 237-7837.
