Restore Accountability

The desire to control zooming medical costs while ensuring high quality care is what led Americans and their employers to make health maintenance organizations the predominant providers of health care in the United States.

In large part, HMOs are accomplishing the first of those goals. But concerns about the second have produced a growing file of protests and outrage stories, explored last week in “The HMO Backlash,” a series by Times Ventura County staff writer Daryl Kelley. The series described a rebellion by doctors and patients against the shift of decision-making from physicians to insurance managers. Kelley told the stories of Ventura County doctors and patients who have given up on the HMO system--although 85% of employed Americans now belong to HMOs.

The Times intends to pursue this issue vigorously in months to come, emphasizing Ventura County residents’ desire for quality, affordable medical care and steps being taken to deliver it.

The gap between what the HMO approach offered and what it is delivering is a matter of nationwide concern. In Washington, D.C., as in Sacramento, measures are being debated that seek to restore accountability and consumer confidence. As improvements to the system are crafted, here are some steps that will help:

* Patients should take a more active role with their doctors and insurance representatives, insisting on effective treatment and questioning decisions that seem based more on cost-cutting than conscientious care.

* Doctors should reject--or question ethically--HMO contracts that force them to see too many patients and pay them more for not treating patients with costly care.

* The state should proceed with plans for a strong HMO watchdog agency. Its emphasis should be on consumer protection and advocacy, not merely on business regulation.

* Lawmakers should change state and federal laws to make HMOs and insurance companies--not just doctors--accountable for policies that contribute to the death or injury of patients. A move to amend a federal law that limits patients’ ability to sue HMOs and insurance companies is stalled in Congress. At the very least, patients need a review board to which they could promptly appeal decisions to deny care.

In Congress, Republicans and Democrats agree that reforms should include a patient’s right to emergency-room treatment without HMO approval, the right to appeal HMO denials to an independent third party, and doctors’ right to discuss with patients the full range of options, not just the ones covered by a patient’s HMO.

The “managed care” approach followed by HMOs has been so successful at controlling costs that a retreat to the way things used to be is not an option, no matter how dearly some might wish for it. The challenge is to refine the system to put patients back in charge of their own fate, to put doctors back in charge of medical decisions, and to put responsibility for errors and mistreatment where it belongs.