The price of good health? HMO policies center of national debate

Art Nadler

Saturday, Oct. 31, 1998 | 10:51 a.m.

When Edith White developed uncontrollable tremors from multiple sclerosis this spring, she thought it was the beginning of the end. She could not feed herself, or even hold a glass of water.

Eventually, White thought she'd end up in a wheelchair. So in desperation, she turned to the Internet and found a new type of brain surgery using lasers to control tremors. The procedure, Thalamotomy, had been successful on Parkinson's patients, but it wasn't covered under her health-care insurance policy.

Determined not to give up, White appealed to her insurer, Health Plan of Nevada, a subsidiary of Sierra Health Services Inc. It approved the procedure, on the condition she pay higher out-of-pocket expenses. She agreed and had the surgery done on the left side of her brain.

What White wasn't counting on were limits on rehabilitation she would need after surgery. Her policy covered 60 days of outpatient physical rehabilitation -- not consecutive days -- just what she and her physical therapist could fit in during two months.

White thought that would be enough, but once she got into rehab, her therapist said she needed a lot more.

White, 39, had both her doctor and rehabilitation therapist request more physical therapy. But she was denied.

Her case illustrates the arguments of many patients and doctors, that quality patient care often gives way to a seemingly higher priority -- the bottom-line attitude of Health Maintenance Organizations.

Assemblyman Jack Close, R-Las Vegas, himself a physical therapist, says he too makes that same argument and plans to offer a solution through the Legislature.

Close and several legislators are supporting the creation of a state-funded ombudsman position, or a similar post in the state Insurance Commission, to help people obtain more rehabilitation when needed.

Assemblywoman Vivian Freeman, D-Reno, said she recently talked with Insurance Commissioner Alice Molasky-Arman about having a state person handle complaints. Freeman said she is also working on a bill draft for such a position.

"I had to change the model I was trained to do in rehabilitation," Close said of his own frustrations. "Patients don't get months anymore. Patient care is not a high priority now. Rehabilitation is suppose to be one on one."

Realizing that health-care costs need to be controlled, while still maintaining the best care for patients, Close thinks outpatient rehabilitation must be determined by what he calls the "verification of progress of the patient."

This would operate, he said, by having an appeal process that works, having someone at the HMO level properly trained to review a patient's rehabilitation, and an ombudsman at the helm overseeing the whole process.

Assemblywoman Barbara Buckley, D-Las Vegas, says that doesn't have to happen.

HMOs and other managed care organizations, she said, have to abide by Assembly Bill 156, even when it deals with rehabilitation.

AB156, which was passed by the 1996 Legislature, toughened the standards under which HMOs can deny care.

"I would like the therapists to try and exercise their rights and to file complaints with the (state) Insurance Commission," Buckley said. "The decision for more rehabilitation should go back to the treating (primary care) physician."

Today, a frightened White walks slowly, trying to balance herself so she doesn't fall. She still has tremors on the left side of her body. She wants to have surgery done on her right side, but won't until she is assured her HMO will cover more rehabilitation.

"Edith still needs to work on her balance and coordination," said Alex Delgado, her rehabilitation therapist at NovaCare Outpatient Rehabilitation. "Once you have an injury to the central nervous system, it's important to get the proper care in the first six months. And after the first year, your return on what you put into therapy is diminished significantly."

"They like to frustrate you," White said in disgust. "If you are chronically ill or seriously ill, HMOs are not the place to go."

Charlene Herst, community and public relations coordinator with Sierra Health Services Inc., said Delgado was suppose to work with White's primary care physician to arrange for more rehabilitation. She said that never happened.

Delgado said he did appeal to HPN and his request was denied.

Dr. John Schaeffer, the neurologist who treated White, confirms what Delgado said.

"They (HMOs) always approve initial treatment of six to 10 sessions. Getting them to approve longer treatment is very difficult," Schaeffer said. "I think patients are suffering because of this. They are having more pain than they should.

"Almost anyone I send to physical therapy, they (the HMOs) tell the patient it is not medically indicated. The patient is mislead."

Dr. Samual Wise, the state representative for the American Academy of Physical Medicine and Rehabilitation and a founding member of the Nevada Health Care Reform Project that lobbied for AB156, said people need to carefully read their health-care policy.

It's important, he said, to know if you have 60 calendar days of rehabilitation, or 60 consecutive days. A policy holder also needs to know what equipment and replacement equipment is available and if repairs will be approved.

"Germs don't understand politics," a frustrated Wise said. "Some people need longer lengths of stay... People with brain injury really get a short end of the stick.

"Is health care a privilege, or a benefit of having a society?"

But Lynn Maguire, president-elect of the Nevada Physical Therapy Association, doesn't see a problem with shortened rehabilitation therapy. She thinks patients in the past had been overcharged by some physical therapists, and the new HMO guidelines are beneficial.

"Now, we have to be more efficient and have to assess the need of patients more carefully," Maguire said. "It's hard when you have capitation, but I think it's better."

The problem, according to Candis Lee Englant, compliance officer for the health maintenance organization Amil International of Nevada, is that employees are controlled by the policy their employer buys. Some policies provide for 30 or 60 calendar days, and others for the same period in consecutive days.

"If there is a plan of rehabilitation treatment, we wouldn't stop it," Englant said. "We will not have anyone (who reviews therapy) say no to a plan of treatment, unless it's a physician reviewing it."

Englant suggests that employees, who are unhappy with their coverage, talk to their company health insurance group administer or immediate supervisor. She also stresses that rehabilitation therapists should not be shy about getting to know insurance companies' benefits managers.

"Rapport with a medical director is helpful any time you are in long-term medical procedures," Englant said. "You may be able to get other benefits within the policy that you don't know about."

John Peters, chief financial officer at Sunrise Hospital and Medical Center, emphasizes that patients should be aware of any capitation agreements between rehabilitation centers and HMOs.

Peters said the hospital, which operates Sunrise Health Strategies sports medicine and rehabilitation center, has no such agreements.

Currently, there also is a movement in Congress to repeal capitations in federal programs.

A provision of the Balanced Budget Act of 1997 is being attacked. Proposed bills seek to repeal imposed outpatient rehabilitation Medicare capitations of $1,500 for physical therapy and speech pathology and $1,500 for occupational therapy scheduled to begin on Jan. 1, 1999 through Jan. 1, 2001.

Congressman John Ensign, R-Nev., introduced the "Reinstatement of the Medicare Rehabilitation Benefit Act of 1998" to repeal this section and direct the secretary of Health and Human Services to come up with a system based on physician diagnosis.

Sen. Charles Grassley, R-Iowa, introduced a similar bill in the Senate.

Congressman James Gibbons, R-Nev., has endorsed Ensign's bill. Sen. Harry Reid, D-Nev., signed on for Grassley's bill.

A representative in Sen. Richard Bryan, D-Nev., office said he hasn't decided whether he will support the bills.

Terese Strombeck, health insurance specialist with the Health Care Financing Administration (HCFA) in San Francisco, pointed out that Medicare rehabilitation capitations have always been part of the Social Security Act.

Limits are presently $900 and being raised to $1,500. They were $750 before 1994 and $500 prior to 1990.

However, the secretary of Health and Human Services, Strombeck said, is proposing to switch from a capitation amount to a time-based method of paying for outpatient rehabilitation by Jan. 1, 2001.

"I think payments should be expanded," said Ed Fend, vice chairman of the state Legislative Committee of the American Association of Retired Persons (AARP). "With $1,500 -- you don't get much. There's going to be a lot of politics involved here. I hope it's stopped. I think a medical facility should make the decision."

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