Monday, June 28, 2004


Health maintenance organizations, never at the top of the warm-and-cuddly list, dropped a few notches with a comment in today’s Boston Herald:

HMO leaders say, however, they only make decisions about whether to pay for care, they don’t deny it.

The context is the recent Supreme Court decision against patients suing the organizations for denying care, which prompted the Boston Herald to write about Massachusetts’ appeals process, which takes place when treatment is requested, rather than when it’s too late and denied care has resulted in damage of some kind.

The comment by HMO leaders hints that they can’t be responsible for damage resulting from denied care, because the patient is always free to get care on their own. This is ridiculous, since direct-payer health care is generally possible only for the very wealthy -- or for the kind of care unlikely to bring on a lawsuit or even an appeal.

This is similar to the story over at U.S. Citizenship and Immigration Services to someone trying desperately to get out of the country for a funeral and ensure the right to return. What was needed was “emergency advance parole,” but this was complicated by a document missing because of an agency mistake.

Two workers there gave the same asinine answer to the distraught immigrant: Go ahead and leave! Then just ask to get back in. That way you don’t have to worry about the document, see. No problem.

Of course, it’s no more reassuring to hear that from an agency that’s retired an active file than it is to be told by HMO officials that patients should go ahead and pay for a procedure expensive enough that insurers don’t want to pay for it.

Even the appeals process has a built-in contradiction, also not noted in the Herald piece: The burden of paperwork and effort falls on the patient, who are by necessity sick and vulnerable, and HMO doctors, who are already pressed for time, forced into “seeing thousands of patients a year to survive, and the result is hamster care, or treadmill medicine,” according to Jack Lewin, head of the California Medical Association, in a recent Knight-Ridder chain article. An internist in the same article broke that down as being more than 30 patients a day.

HMO leaders, of course, don’t insist they see that many patients. They can choose not to and see their practices fail. Although, come to think of it, health maintenance organizations don’t have to deny care to patients or pay doctors so little. They can do the opposite and see revenue plummet.

A very freeing philosophy, even if it is very expensive.

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