HMOs Tough To Endorse
The health-care debate is primarily focused on the uninsured. What follows are the misadventures of someone who is insured and became a victim of the typical HMO bureaucratic morass. It’s an insight into a system that creates angry patients, overworked doctors and unmotivated, rude personnel.
This is a scenario familiar to many of the 21 million Californians enrolled in HMOs.
My friend injured her knee Oct. 26. As of today, she is still awaiting treatment, in dire pain and unable to walk. She immediately contacted her primary care doctor. He could not see her until Nov. 12, or 17 days after the injury.
After the visit he submitted a request to the HMO for authorization to see an orthopedic specialist. The best the orthopedic group could do was schedule an appointment with a physician’s assistant Nov. 24 (12 days later).
The assistant told her she definitely needed to see an orthopedic surgeon, and he annotated the chart “urgent.” The earliest appointment was Jan. 5, subsequently changed to Dec. 29 after she pleaded that the pain was unbearable. The office manager’s snooty reply: “It was not fair to overbook the doctor.” In other words, please suffer in silence.
Ruffles and flourishes! On Dec. 29 (35 days later), she saw the surgeon and he agreed to ask for authorization from the HMO to do surgery. After several unreturned calls to the orthopedic group, my friend secured a copy of the authorization from her primary care doctor and alerted the orthopedic surgeon’s office of its existence. They assured her that they would call as soon as they found their copy.
Unreturned phone calls continued, and finally, on Jan. 20 (22 days later), the group informed my long-suffering friend they had the authorization. The first available date for surgery would be Feb. 19 (29 days later).
Four months after the injury and suffering unrelenting pain the entire time, she may finally get the treatment she should have received within two weeks of the injury. Compare this to the experience of another friend insured in a PPO. Suffering a less painful injury, surgery was performed by the same orthopedic group within 10 days of visiting the surgeon. I’m sure there is a long-winded, bureaucratic explanation of the inequity.
Triage is a medical process used in combat and mass injury settings. It involves determining the order of treatment by the severity of the injury and threat to life. Pain level is also considered. Unfortunately, HMOs, doctor and hospital schedulers do not apply the latter standard to patients. Nor, I’m afraid, do providers adhere to “first come, first served.”
What standard do they apply to patient scheduling? The answer is too often the almighty dollar. PPOs pay providers substantially more per patient than HMOs. Therefore, HMO patient-to-provider ratios are very high, particularly for primary care physicians. Hence the unconscionably long waiting times for appointments.
Fearing financial retribution, many doctors will not challenge HMO decisions that are not in the patient’s best interests. The unpleasant truth is that HMO patients are treated no better than Medi-Cal patients. HMO profits depend on enrollees who visit the doctor infrequently and require less treatment time, e.g. young healthy adult males. HMOs are not for those of us between the age of 50 and 65.
Perhaps my friend should have hopped (tough to do in her condition) on a plane to Canada for some good old-fashioned socialized medicine. The turnaround time could not have been any longer.
The good news: Help is on the way. Beginning in 2012, mandated turnaround times for California HMO providers go into effect — no more than 10 business days to see your general practitioner, urgent-need patients must be seen within 48 hours, and return calls made within 30 minutes. Good luck staying healthy until 2012!
Get in touch PAT GRANT has lived in Glendale for more than 30 years and was formerly a marketing manager for an insurance company. He may be reached at sfgranted@gmail.com.
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