Helping People Navigate Health Care
Once upon a time, your “health care provider” was the doctor who moved to town, hung out a shingle, knew your name and treated you and your family for a lifetime. How simple. How outdated.
Today, getting to a doctor most likely means diving into the confusing and often impersonal sea of managed care, mastering the language of plans and provider networks, following dizzying arrays of protocols and dealing with intermediaries who determine access to doctors and hospitals.
The system, if it can be called that, frequently bogs down--at the doctor’s office with appointment delays, with a physician group trying to hold the line on specialist referrals or a health plan refusing to pay for some kinds of care.
In the middle of it all sits a lone patient--lost, tiny and trapped like Jonah in the belly of a whale.
Fortunately, there are people trying to toss a lifeline.
In its first 18 months, a privately funded pilot program has helped thousands of Sacramento-area consumers navigate their health care plans.
The Health Rights Hotline offers educational outreach, a telephone help line and staff of counselors operating independently of doctors, hospitals and health insurers.
“We’re setting up the model for independent assistance,” said Peter Lee, an attorney who serves as the hotline’s project director. He explained that Sacramento was chosen as the test bed because it offered a good mix of urban and rural residents, a manageable size--about 1.5 million people--and a heavy concentration of residents enrolled in managed care plans. A trio of nonprofit health care charities--the Kaiser Family Foundation, California Wellness Foundation and Sierra Health Foundation--provided $4 million to operate the program through 2000.
The ombudsman program assists consumers who get their health insurance through government-funded programs such as Medicare and Medi-Cal, and through employer-sponsored and individual plans, including HMOs and preferred-provider organizations.
It also provides the insurance companies with surveys that show where the problems are turning up.
“We at Health Net have the opportunity to learn about what the experience is of consumers far beyond our own membership and then incorporate that into our own strategy for providing better health care and service to our members,” said Dr. Yvonne McDowell, associate medical director for special projects at Health Net, based in Woodland Hills.
Already, a similar program has sprung up in New York City. Florida and Vermont are putting together ombudsman programs to assist the bewildered or those needing a boost to get what they deserve.
A review of the hotline’s first year--from July 1997 through June 1998--showed that 10% of the callers sought help getting coverage, 33% wanted to learn more about their insurance and 57% asked for help solving a problem. The problems included care delayed and denied, inappropriate care, payment disputes, difficulties getting prescription drugs and trouble getting to a specialist.
The Sacramento experiment is up and running as President Clinton is pushing Congress to pass legislation known as the patient’s bill of rights. Among its provisions, the bill of rights would give health plan members enhanced access to specialty care, the right to timely emergency room care, stronger protections guaranteeing confidentiality of medical records and the right to appeal denials of care.
It also comes as health plans have been moving to address public anxiety about managed care by easing some restrictions that limited patients’ ability to choose doctors and make it easier for patients to resolve grievances against the plans. Earlier this month, a group of California health plans voluntarily agreed to allow members to take complaints about denial of care to an independent panel of doctors. If the panel deems the treatment necessary, the plan must provide it.
Solves Problems Without Arbitration
While interested groups nationwide try to determine who should review disputed cases, the Sacramento-based hotline is solving the majority of the problems that come its way before they get to litigation or arbitration.
“More than 75% of the problems are resolved at the level of the doctor and the medical group and without any formal appeal process. Sometimes the resolution . . . may be as simple as learning how to better use the system, to find out who is the right doctor or nurse who can make things happen in the medical group,” says Lee, noting that health plans have passed much of the financial risk--and responsibility--traditionally borne by insurers onto medical groups, effectively turning them into “mini-HMOs.”
He says an independent assistance program “can help people long before independent third-party review kicks in.”
Take the case of Dave Rafferty, his wife, Lynmarie, and their premature twins, Paige and Hannah.
The girls were born 10 weeks early in September. A week later, as they lay in a hospital neonatal intensive care unit, the family doctor’s medical group declared bankruptcy.
Suddenly, the doctor was no longer affiliated with that hospital. The health plan demanded the babies be transferred to another hospital 20 minutes further from the family home in Rocklin, Calif.
The first thing Rafferty thought about was how risky it would be to transport his tiny daughters, each weighing about 2.5 pounds and still hooked up to monitors and machines.
“Who’s going to explain if that ambulance gets in an accident?” he wondered.
But the insurance company was playing hardball. It offered the Rafferty family various incentives to move the children and threatened not to pay for the hospital stay if the newborns stayed put.
An irate Rafferty, a production manager for a manufacturer of robotics and underwater devices, telephoned the hotline from the ICU.
Within five minutes, hotline workers were able to pull the family’s policy up on a computer, review it and determine the insurance company had no right to move the babies to another facility.
“The next day, I informed the insurance company we would not comply with their request,” Rafferty said. Hotline counselors helped draft an appeal letter and advised him to fax a copy to the California Department of Corporations, the state agency responsible for regulating HMOs.
Days later, the health plan backed down, allowing the Rafferty babies to stay where they were. And it paid the entire $800,000 hospital tab--except for a $5 co-payment.
Coverage Was Unjustly Denied
Nina Allen, a 29-year-old student and mother, also dialed the hotline when she got caught between her Medi-Cal coverage and her HMO. Medi-Cal, the federal-state medical insurance program for the poor, said she was entitled to two chiropractic visits a month for back pain; her health plan said she had no such benefit.
“There’s no bridge between the two,” she complained.
Allen recalls an HMO member services representative telling her: “If you think chiropractic care is more important than your health care, I can disenroll you right now.” She contacted the hotline, and they helped her request an administrative hearing. The day before the hearing, the HMO sent Allen a letter acknowledging that it had improperly denied her the chiropractic services covered by Medi-Cal.
The hotline “pushed on doors you can’t get open,” she said. “They get results you can’t get.”
John Rother, director of legislation and public policy for the American Assn. of Retired Persons in Washington, which represents Americans over 50, supports ombudsman programs.
AARP is urging states to adopt such programs, which it prefers to call consumer assistance programs, and hopes that passage of a federal patient bill of rights would give the effort a big boost.
“A lot of times what we find is not necessarily bad people running the plans, or people acting out of greed, but just as often we find confusion . . . [for consumers and] for the people who are trying to provide services,” Rother says.
Lee says ombudsman programs could be financed with general fund tax dollars or by tacking surcharges onto insurance premiums. He estimates they might add 5 cents to 10 cents per person per month. Ron Pollock, executive director of Families USA, a consumer health care advocacy group in Washington, says 15 cents to 20 cents is more realistic--and still minimal.
“We are deeply involved in trying to promote the concept of ombudsman,” Pollock said.
Rother sees a particular need among elderly Americans who leave familiar fee-for-service plans to join Medicare managed care programs. When they were working, they could seek help through their employers’ benefit offices. Now they’re essentially on their own.
“Other than this kind of project, there’s no one place for help,” Rother said.
But there will be.
Next month, the state of Vermont will begin an ombudsman program, independent of state government, to serve people regardless of who provides their health care coverage. Florida has enacted legislation--not yet funded--for a program in which volunteers would provide consumers with help navigating the plans. New York City has provided $3 million to launch an assistance program for residents in managed care that will begin by serving disabled, elderly and Medicaid recipients.
Legislation will be reintroduced in Congress to provide states with block grant money for ombudsman programs, Pollock said.
Still, ombudsman programs like the hotline have limitations.
“If what you want from a plan is not covered or is clearly experimental or clearly inappropriate from a plan’s point of view, you’re not going to be able to call a number like this and get that turned around,” Rother said.
And, notes Lee, the ombudsman has the “ability to advocate and inform. We don’t have the formal power of a judge to change a decision.”
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Hotline Problem Calls
Distribution of problems reported by callers to the Health Rights Hotline from July 1, 1997 through June 30, 1998. Of the more than 2,400 calls, 57% were from consumers seeking help with a current problem; an additional 10% wanted information on how to obtain insurance; and 33% wanted more information on plan choice or how to navigate through the system.
Customer service: 14%
Delays: 8%
Denials of care: 16%
Inappropriate care: 14%
Payment for care dispute: 11%
Prescription drug problem: 7%
Specialty access problem: 10%
All other problems: 21%
Numbers may not add up to 100% due to rounding
Source: Health Rights Hotline
Medical Group May Be Behind Some Problems
Peter Lee, project director of the Sacramento-based Health Rights Hotline, offers some basic advice to consumers who hit a roadblock with their health care plans:
* Find out where the problem is. If it’s a denial of care, find out who is doing the denying--the doctor, medical group or health plan. As health plans shift more responsibility to medical groups, the doctor groups are making more of the decisions.
* Instead of starting with your employer, start by talking to your doctor. Get your doctor on your side.
“Ninety percent of the health plans can be made to work for you if you know the right doctor and get that doctor to be your advocate,” Lee says. “Your choices are driven by the medical group you’ve chosen. Where we’re seeing the points of friction are more and more at the medical group level.”
* Talk to and work with your health plan. Health plans contract out so much work that they may be able to intervene on behalf of their members, Lee says.
