California and the West : Who Remembers What the ‘M’ in HMO Means?

They said my plan didn’t cover it and it wasn’t necessary anyway. . . . [Bleeping] HMOs. Bastard pieces of [bleep]. . . . I’m sorry.

--Carol the waitress

It’s OK. Actually, I think that’s their technical name.

--Dr. Bettes

Movie audiences all over America cheered Oscar winner Helen Hunt--playing Carol with a chronically ill son--when she ripped HMOs in the 1997 film “As Good As It Gets.” Her tirade became a national rallying cry for HMO reform.

Millions of people could relate because they have their own HMO stories.

Mine is being denied an exam before periodontal gum surgery--then being refused payment for the surgery because the exam was considered inadequate. There also was a doctor who tried to deny me a blood test for prostate cancer. I had no family history of cancer, he explained, and my HMO didn’t provide much money for routine care.

Common gripes. But there also are real horror tales--of patients dying or being disabled because HMOs refused them care.

“I’d refer patients with injured knees or ankles back to their HMOs for consultation with an orthopedic surgeon or for an MRI and they’d be denied,” says Assemblyman Martin Gallegos (D-Baldwin Hills), a chiropractor and chairman of the Assembly Health Committee.

“They’d simply be told to go home and take some Tylenol or Advil and the problem would go away. Some patients sustained permanent damage because they weren’t provided appropriate care.”

Gallegos is one of two dozen legislators pushing roughly 70 HMO reform bills. There’s a rush to make some sense out of this noncohesive, oft-conflicting pile of proposals before the Legislature recesses for the year Sept. 10.

Many negotiators--gubernatorial aides, lawmakers, lobbyists--predict there’ll be a modest but significant deal because the political climate is right. “They [politicians] want to rock ‘n’ roll,” notes Beth Capell of Health Access, a consumers lobby.

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No issue at the Capitol this year, however, has produced more acrimony between the governor and the Legislature--and more Carol-type language--than HMO reform.

Gov. Gray Davis hesitated getting into health care. He was busy on education and the budget, aides say. When the Democratic governor finally did enter the fray in July, it was to urge legislative committee heads at a private meeting to slow down on reform. Just ignore him, they were admonished by their angry leaders, Assembly Speaker Antonio Villaraigosa of Los Angeles and Sen. John Burton of San Francisco.

Davis took a PR beating on that because only days earlier he had raised $100,000 in political money from health insurers. Bad timing, aides admitted. But they insisted the two events were unrelated.

Davis soon stepped in it again at a meeting with the San Francisco Chronicle editorial board. Ignoring all civics books, he declared that the Legislature’s “job is to implement my vision.” But on HMO reform, the governor continued, he had offered little vision while running for election because it was not a priority issue. “Did you see one commercial on health care?” he asked. Well, yes, it later was pointed out--he did run a TV ad promising “to rein in these HMOs.”

Davis has been advised by his private pollster that HMO reform is not a front-burner issue for voters. “The pot is boiling, but it’s a long way from bubbling over,” asserts the pollster, Paul Maslin.

“It’s a second-tier issue. Education and crime still are at the top.

“What I’ve said to the governor is there’s not a clear public consensus. It’s not like villagers with pitchforks and torches are attacking the castle.”

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Democratic legislators are demanding some HMO reform, however, so Davis two weeks ago outlined a package of bills he’d sign:

* Binding review by independent doctors of treatment denials.

* Limited opportunity for harmed patients to sue HMOs.

* A new HMO regulatory department based in the state business agency.

* New regulation aimed at assuring the fiscal solvency of doctor groups.

Details still are being hotly debated. For example, consumer advocates argue that the new regulatory department should be based in the patient-friendly state health agency. Davis insists that since HMOs are a business, they should be regulated by the business agency.

Davis also may well sign bills mandating HMO coverage for mental health care, birth control pills, cancer screening, diabetic supplies, hospice care and treatment for PKU, an inherited disorder. He wants to emphasize prevention.

The politicians also should emphasize this: “Technical name” aside, the “M” in HMO means health maintenance, not just money.