It’s Time to Revisit Universal Health Care

“Survey Ranks PacifiCare and Health Net Best HMOs in State” [June 24] implies that HMOs in California provide high-quality care.

Excluded from the article, unfortunately, was the most alarming result of the survey: Well over half (59%) of the doctors surveyed reported that the quality-improvement programs of the HMOs were “poor” or “very poor.”

Since the survey was of administrators of physician groups that contract with the HMOs, and since the physician groups, rather than the HMO fiscal intermediaries, deliver quality, the lack of quality improvement may be significantly underreported.

Although the managed-care industry has responded to the marketplace demand for cost containment, quality enhancement has remained elusive.

We can have both cost control and improved quality, while returning to the patient free choice of physician, by unifying the fiscal intermediaries under one universal program. Costs can be controlled through global budgeting. Quality can be attained only by placing the well-trained professional in an environment that exclusively promotes the mission of optimum patient care.

The current market incentives rewarding excessive services, or the withholding of services, must be eliminated.

At 14% of our GDP, we already spend more than enough to provide quality care for everyone. Providing care limited only by the constraints of a national budget will bring us much closer to the goal of quality than the current defective financial disincentives of the medical marketplace. It is time to reopen the discussions of a universal health-care plan.

DON R. McCANNE, MD

San Juan Capistrano

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A more critical review of the external review programs pushed by the HMO industry shows the reason that HMOs are for them in the first place: They have a huge escape hatch.

If the HMOs deny care as “not a covered benefit,” the companies are not subject to independent review. Denials based on the fact that treatment is “not a covered benefit” simply disappear into the haze at the state Department of Corporations.

The “not a covered benefit” defense proliferates. For instance, autism treatment is denied under mental health exclusions of coverage, though autism is not a developmental mental illness but a biological-based brain disorder. Treatment for anorexia, an eating disorder, is denied on the basis that it is a mental illness treatment. Reconstruction of breasts after mastectomy for breast cancer is denied under a cosmetic-surgery exclusion. Even reviews for “medical necessity” that come out in the patient’s favor--should they survive first the 60-day wait for the HMO’s internal process, then the time lines added in new HMO-backed legislation--are referred back to the Department of Corporations for action, which cannot be trusted.

Moreover, every determination made by the nameless, unidentified reviewer can be used in court against you, although the standards of perjury do not apply to HMOs that withhold medical evidence. The kicker is that the independent-review legislation is not effective until 2000. Politicians want something to show voters on election day, and the HMO industry does not want to be held liable in a court of law, so it must offer up its own alternative. Both know Gov. Wilson will not sign a bill not supported by the industry.

Only the legal threat of damages against an HMO should that patient not get appropriate care will compel the time-sensitive hospital admission or drug approval that can save a life. Our politicians should stop acting like used-car salesmen and start hustling to build a quality product.

JAMIE COURT

Director,

Consumers for Quality Care

Santa Monica

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The United States is the only industrialized nation without a national health-protection plan for its citizens.

We should be embarrassed at how far behind the rest of the world we are in terms of treating ourselves with proper health care.

HMOs are an atrocity, and each one of us has a nightmare of dealing with HMOs for their “mangled-care” policies and “bottom-line profit” procedures that have in many cases resulted in serious injury or even death.

WAYNE KURTZ

Hollywood