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The Following Items Are Not Covered By Your HMO

Casey Boland

Tell a friend while in a public place that you're concocting an expose of the health care system and witness the storm of condemnation bystanders within earshot will rain upon the subject. Nearly everyone can spin a tale about a run-in with the medical industry. Even mainstream media, often the last stop for massive strife and gripes with major national institutions, have adopted a "let's bash" attitude towards HMOs and insurance companies. So it's no secret that health care in the United States is a cruel joke. The public laughs because it is such a farcical failure and the CEOs of the HMOs laugh because the system that benefits them more than anyone else remains in place and threatens to go unscathed, save for minor revisions. But hope is not yet lost. The cracks grow daily and the massive distrust spreads like a fire on the veil of quality covering medical care. Sure, you've heard the basics about what is wrong, but not much about how to truly remedy the problems. We hear about the sickness but not about the cure. What follows details the problem, the source, the extent and the possible solutions that won't get much media coverage (anything that challenges the capitalist/corporate structure never does). Read on kids, and if you haven't delved deeply into the U.S. health care crisis, prepare to be shocked, angered and appalled.

An Apple a Day Didn't Keep the Doctor Away - Having No Insurance Did

On two separate occasions in the past year, I came face to face with the monster that is the U.S. health care system. During the month of June, as I hunted fiercely for a job, some pesky pathogens invaded my body. In my sick and debilitated state, I decided that I needed medical attention and headed on over to the Hospital of the University of Pennsylvania. I figured that since it had a clinic (everyone told me that it was a clinic) it must be cheap. How could they be so odious as to charge exorbitant fees in such a hallowed place for the caring of disadvantaged people in need?

I waited over an hour for a five minute exam. The nurse took a sample of the scum off my tongue, rammed a rough injection of penicillin into my backside, and sent me on my way. A month later I received a bill for $28 - the cost of the throat culture. Hallelujah! I thought. Health care ain't so bad after all. Wrong. A month after that, I ripped open a bill for $265 - the price of an exam.

Fast forward five months-I have a job with benefits that allow me to go to a fancy dentist. I undergo a particularly brutal cleaning and check-up. Turns out I have some problems. I go back for a consultation visit and I understand just how ridiculously expensive dental work can be. I gaze at the dental assistant in utter shock and total horror as she says the amount: $2,100. Two thousand and one hundred dollars and no cents (oh ... what a relief). I wasn't buying a new car or a house or an Armani suit worn by Armani himself. I was buying repairs to two teeth rotting in my gums as I sat there. My insurance? It covered $800 for the fillings.

This, my friends, is only one tiny morsel from the mountainous heap of nightmare experiences spawned from the health care industry in the U.S. And I had it easy. Most Americans, from the middle-management goateed dude to the church-hopping conservative grandma, agree that health care in America is sick and in need of a good doctor. Yet powerful folks-insurance companies, the American Medical Association and other major (and well-paid) players in medical care make sure that the system stays sick. They rake in millions off the ill health and accidents of others. They seem to feel that their economic health will be jeopardized by devoting comprehensive medical attention towards the health of millions of people. It's a complex issue, yet what remains clear are three indisputable facts: 44 million people have no health insurance (many of which are children), those who can afford the care often complain that it is substandard, and profits do affect how much care an individual will receive. As most will readily say: profits are more important than people. This is a bold statement that requires evidence and justification, so read on.

Nature of the Beast

Criticizing HMOs and health care is about as American as complaining about work. So how did it get this way? The American health care system is a system where the individual is responsible for the cost of any medical procedures. Health insurance is designed to offset the exorbitant cost of these procedures. "Managed care" is becoming the most popular form of insurance. Businesses own health care facilities and consolidate different health services under one group or plan. Managed care exists mostly as HMOs (Health Maintenance Organization) in the United States, though not exclusively. The hallmarks of an HMO are complete oversight over patient ("customer" or "consumer") care, contractual relationships and organization of providers giving care, and benefits tied to managed care stipulations.

Managed care arose in 1929 and continued onward as a "minor presence" with the KaiserHealth Plan during World War II. Medical care costs soared throughout the 60s and some saw managed care as the solution to skyrocketing prices for procedures and coverage. But it was the HMO Act of 1973 that blazed a trail for the HMO takeover in the 80s and 90s.

An HMO works like this: you have your primary care physician, the person you see for routine health exams. Only they can refer you to a specialist for any sort of procedure. More times than not, primary care physicians are part of medical groups, an organization whose purpose is to contract health care. The relationship among all the actors is commonly referred to as the three Ps: patients, providers and purchasers. The purchaser pays for the care: employers, government or insurance companies. For instance, I enjoy the wonderful coverage of Aetna U.S. health care. My purchaser is my boss who buys coverage from Aetna. My provider is a doctor I have yet to see and I am the happy patient. I can't see the doctor I've gone to since I was a kid-they are not with Aetna. If I need an X-ray, my doctor must write me a referral. Dentists work the same way. HMOs aren't the only health care option in America, but they are becoming the most popular and the most powerful.

When I first learned about my benefits from work, it sounded like utopia. I'd have inexpensive health care, be covered if I suffered a major accident- the HMO seemed like a good friend ready to care for me like mom if I needed it. This is sadly not reality. HMOs provide "rationed care." As a fact sheet on HMOs succinctly put it, "An HMO is a for-profit corporation with responsibilities to its stockholders that take precedence over its responsibilities to you. The HMO directly controls the amount of health care that the doctor is allowed to provide to you." This is the crime that has received much attention. Doctors, surgeons and any health care employee within an HMO must ultimately answer to the HMO.

Here are just some of the trends occurring within the for-profit HMO-dominated health care industry:

- Over the past four years, hospitals have fired thousands of registered nurses to maximize profits. Seventy-five percent of U.S. hospitals have undergone "restructuring," meaning that they downsized nursing staffs, replacing them with aides and "patient care technicians." According to an Ad Hoc Committee to Defend Health Care information sheet: "A day-shift nurse may care for seven or eight patients and, at the same time, be responsible for supervising an aide assigned to care for four or five others. This means that the nurse will be effectively in charge of 12 patients."

- One study found that 99 percent of California hospitals reported less than 120 hours of on-the-job training for newly hired nursing personnel. The majority of hospitals provided less than 20 hours of classroom instruction and 88 percent provided less than 40 hours of instruction time. These people "insert catheters, read EKGs, suction tracheotomy tubes, and changed sterile dressings."

- A questionnaire of 37,000 patients conducted by the American Hospital Association in 1998 found that 33 percent felt they went home too early. Thirty percent thought they were not warned about possible problem signs associated with their condition after they left the hospital, 23 percent said they received little information about their condition, while 29 percent cited problems with care and the lack of coordination between various providers.

- Over 100,000 people lose their health insurance every month.

- Over 25 cents of every care dollar is spent on paperwork, advertis- ing and multimillion-dollar CEO salaries.

- Doctors are given financial incentives to give less care.

Will One Beast Reign Supreme?

A few giant firms own or control a growing share of medical practice says Physicians For a National Health Program (PNHP), a coalition of health practitioners devoted to curtailing the corporate takeover of health care before it's too late. "The winners in the new medical marketplace are determined by financial clout, not medical quality. The result: three or four hospital chains and managed care plans will soon corner the market, leaving physicians and patients with few options. Doctors who don't fit with corporate needs will be shut out, regardless of patient needs."

Many managed care plans enjoy the act of "delisting," that is, throwing out physicians who don't play along to the tune of the piper and his money bags. Thousands have been delisted in Texas, California, Massachusetts and Washington D.C. The proud physician who appeared in Aetna's newsletter as "Primary Care Physician of the Month" wound up an ex-Aetna physician shortly afterwards when he was seen to have racked up too many costs for patients in his practice. The PNHP describe the problem further: "HMOs/insurers that can raise massive amounts of capital by selling stock have a decisive advantage. Their deep pockets allow them to mount massive ad campaigns ... and set premiums below costs until competitors are driven out .... As a result not-for-profit plans across the country are going for-profit (even Blue Cross), and small plans are being taken over."

Consider the likely fate of Medicare and Medicaid. HMOs have begun feasting on Medicare and Medicaid contracts. This is basically the privatization of government funded health programs for those in special need. According to PNHP, "Nationwide, Medicare HMOs provide strikingly substandard homecare and rehabilitation to the disabled elderly. Tennessee Medicaid HMOs have failed to pay doctors and hospitals for care." Or look at Florida. Half of all Medicaid spending in four HMOs was for administrative costs. Our friends at PNHP had this to say about the legacy of HMO Medicaid care in Florida: "In one plan that enrolled 48,000 Medicaid recipients, 19 % of total Medicaid dollars went for the three owners' salaries. Thousands of patients were denied vital care; sales reps often illegally pressured healthy people into joining HMOs, while discouraging those who were ill .... a cursory state audit found serious problems at 21 of the 29 HMOs."

Since we're on the subject of Florida, one firm owns a quarter of all hospitals in the state-Columbia/HCA. The hospital chain giant plans on gobbling up hospitals in Massachusetts, Denver and Chicago. Likewise, HMOs are multiplying in this health care corporate mating season. Between 1990 and 1995, for-profit HMOs grew 15 fold. By 1996, 630 HMOs existed across the nation, with 459 of those being for-profit. The hungry hungry HMOs that devour more and more patients daily include Oxford Health Plans Inc., United HealthCare Corporation, CIGNA Corporation, Humana Inc. and Aetna U.S. Healthcare. If you're in an HMO, chances are you belong to one of these.

Bikes vs. Cars, 0 - 1

Sure, it's all well and good to rant on and on about how much health care sucks, especially when I have only experienced trivial episodes of such degradation. Yet people around me seem to have had the great fortune of suffering the worst health care has to offer.

Let's look at the case of Rachel. When she set off on the roadways of Philly last summer, she expected it to be a day of fun and excitement, though she would ride into a lot more excitement and a lot less fun than she expected. While riding her bike with her friend up Spruce Street near the University of Pennsylvania, she extended her arm to indicate she was about to cross the road. Within seconds she was on the pavement, unconscious and drenched with blood. A Chrysler LeBaron (speeding and operated by a preoccupied cell phone user) slammed Rachel onto the ground and into a long and tortuous battle with the health care system.

The 21-year-old suffered a long list of injuries: open fracture to the tibia, other bone fractures in her left leg, facial fractures, hemorrhaging in the brain, cuts, bruises and scrapes. Fortunately, her parent's health insurance covered costs of repairing the damages to her body-a price tag in the neighborhood of $54,000. Yet their HMO didn't guarantee complete and compassionate care while in the hospital. "Some of them (the nurses) were very nice," Rachel said. "Most of the others were indifferent, they didn't seem to care one way or another what happened to me. A good amount of them were rather mean. If I'd call them to change my bedpan or to let me go to the bathroom, they would seem very irritated .... They weren't very nice people."

Rachel wallowed in a hospital bed for four days. On her second day, a nurse mentioned that she might be released by the end of that day. But Rachel felt that even four days didn't seem to be an adequate time for her to recover to the point of comfortably leaving the hospital's care. "I think I should have been there longer, considering the fact that they were trying to make sure I could turn around standing with crutches and I was so drugged I kept falling over." As Rachel sees it, the hospital was eager to ship her on her way, rehabilitated or not. She added, "I had just been casted. I still wasn't eating. They had just found that my hemorrhaging had just started to re-absorb and they didn't really follow through on much more checking on that."

Rachel's experiences with the hospital and her parent's HMO were far from behind her when she left the Hospital of the University of Pennsylvania. She required monthly X-rays to determine the progress of bone growth in her leg, as well as physical therapy. Her HMO and her primary care physician disagreed. "The thing they (her parent's HMO-New Jersey Blue Cross Blue Shield) did which was very interesting was, they kept filling out our insurance claims and putting my sister's name .... or my father's name as the patient and then rejecting it," Rachel said. She added that such a tactic was common among HMOs to slow down payments, according to her lawyer.

As for X-rays, the HMO demanded she travel to a hospital nearly an hour away, instead of the hospital she was treated at (not an easy task for someone who cannot drive, let alone walk). Her family primary care physician also had a curious gripe with X-rays. "Even though the fracture has not healed ... they said, 'why does she need X-rays?'" Rachel said.

Even her family doctor, their primary care physician, was not behaving as the classic doctor-knows-best family physician should. Rachel also mentioned, "He said I didn't need physical therapy even though they had never seen me. So they have no idea what state I'm in. He never spoke with my current doctor that's treating me for this. But they just assumed it (that she didn't need PT) and I believe it's because the insurance company just says, 'Give them the least attention they need and move on.'"


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