A Look at HMOs, Rights of Patients

A state Senate committee recently passed a bill to expand patients’ rights to sue their health maintenance organization. Supporters say that if HMOs were held legally responsible for quality care to clients they would focus more on patient welfare than on the financial bottom line. Opponents maintain that such a law would increase exposure of managed care operators to liability lawsuits and drive up the cost of health care.

KARIMA A. HAYNES asked a former HMO patient, the mother of a deceased managed care client and a trade association representative for their views on the issue.

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NANCY HOVEY

50, unemployed payroll clerk, Palmdale

My son Douglas was seeing a psychologist on his own for depression. He went to his primary care physician, who authorized him to see a psychiatrist to determine if he needed antidepressant drugs.

Two weeks after the psychiatrist placed him on medication, [Douglas] indicated that he was having suicidal thoughts. I told him that something was wrong with the medication because he never had those thoughts before. He went back to the psychiatrist and told him that the [medication] wasn’t working. The psychiatrist told him that he needed to be patient. Douglas went back to his primary care physician, who told him to return to the psychiatrist, who doubled the medication.

When Douglas returned to work, he called his psychiatrist and told him he felt like he wanted to throw a chair through the window and jump. His psychiatrist told him to go to the emergency room.

Douglas was admitted to the psychiatric unit. The HMO primary care physician and psychiatrist recommended that he go into an inpatient program. Douglas’ company had not purchased the coverage, so he wasn’t insured. My son freaked out because a 72-hour program cost $10,000 and they wanted him to stay for 14 days.

Douglas discharged himself from the hospital. He went to a hotel and jumped from the balcony of his room.

In my case, it would not matter how much money they give me, I will never get my son back. It’s true that there are too many people who are sue-happy, but they should have some kind of recourse; someone has to be held accountable.

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CYNTHIA TOUSSAINT

38, former ballet dancer, North Hollywood

I was a dance performance major at UC Irvine when I tore my hamstring. I was told to take a couple of weeks off and that I would be fine. The pain started to spread through my body. It began in my right leg and then moved to my left leg, back, stomach, throat and both arms. I have reflex sympathetic dystrophy, a chronic pain disorder.

I was having chronic, excruciating, burning pain . . . from 1982 to 1995, when I was finally diagnosed. Until then, my doctors told me that the problems were all in my head. They made me feel as though it was my fault.

My partner has taken care of me for 16 years; we can’t get married because I would lose my benefits. We constantly sent letters asking for care. My doctor said she would make an appointment for me at a pain clinic and that never happened.

Finally, my mother got me on Medi-Cal. I am out of my HMO and I could not ask for better treatment. I think HMOs are death camps. It is health care for profit and it’s all about the bottom line. They would have done anything to get me out of the system--and they did.

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WALTER A. ZELMAN

President and CEO, California Assn. of Health Plans, Sacramento

The HMO industry has to do a better job of guaranteeing everyone enrolled that they will get the care they need when they need it. That is the fundamental problem that people have with managed care in general and specifically with HMOs.

Liability [lawsuits] are a slow, expensive and inefficient means of getting rewards to individuals who have been hurt. We think there is a better way. What we propose is that if any insurance plan denies a patient anything they need they should have the right to have that decision reviewed by an independent panel of experts.

A [liability law] would have a significant impact on the economy, wages and the numbers of people who are uninsured. As health care costs go up, employers have less money to expand, hire people and invest in new projects. The numbers of uninsured would go up because small businesses would be unable to provide health insurance for employees and self-employed people will be unable to afford coverage.