Patients win round in House against HMOs

Benjamin Grove

Friday, Oct. 8, 1999 | 11:28 a.m.

WASHINGTON -- The House chambers echoed with applause Thursday as representatives passed a bill that would make it easier for patients in health maintenance organizations to see their own doctors and give them more rights to challenge -- even sue -- their health maintenance organizations.

Back in Las Vegas, Mary Schooley spent the day resting at home. Schooley, 56, is weakened by a bad heart and by a confusing battle with her HMO over how much she will pay for a heart transplant.

Time will tell whether the new "patients' bill of rights" will help someone like Schooley and a host of other Las Vegas residents who are tangled in managed care snares.

"There has to be a change in the government system," Schooley said. "Our insurance is out of hand."

The House passed the measure 275-151 after two days of exhaustive debates on four versions of the bill. Supporters called the bill a "historic" victory for workers; opponents, including the House GOP leadership, said the legislation makes HMOs too vulnerable to lawsuits and may force employers to drop insurance plans.

Nevada's two House members, Rep. Shelley Berkley, a Democrat, and Rep. Jim Gibbons, a Republican, voted for the bill.

The bill, named for Rep. Charles Norwood, R-Ga., and Rep. John Dingell, D-Mich., would:

Mary Schooley's situation offers an example of how the issues in the HMO reform debate play out in real life.

Doctors in August told her she needs a new heart, which can cost a staggering $1 million. Schooley is enrolled on her husband's health plan. Charles Schooley, 75, is a security guard at Palm Mortuary.

Schooley said Las Vegas-based Sierra Health Services, Inc., the largest health insurer in the state with more than 200,000 members, had told her the HMO would pay the entire cost of the transplant in Nevada, but only 80 percent out-of-state.

But no Nevada doctors perform the operation.

"It doesn't seem fair," Schooley said. "We're penalized because we go out of state. But we gotta go out of state."

Schooley appealed to several company representatives and later to Berkley.

"I'm scared, just scared that I will wind up paying this amount of money," Schooley said. "What will happen to us? How do other people do it -- without having to be in debt for the rest of their lives?"

But Sierra Health officials said Thursday they would pay for 100 percent of Schooley's heart transplant -- even in another state. Company spokesman Peter O'Neill told the Sun he had checked her records Thursday and verified her procedure was covered in full.

That left Schooley more confused than ever.

"That's not what they have been telling me," she said. "It's wonderful -- if it's true."

Employers, especially small business owners like Palm Mortuary, also got rapped in the House debate over patient rights.

Opponents of Norwood-Dingell argued that it left employers vulnerable to lawsuits, too, even though they had nothing to do with a patient's treatment. They argued the bill might force employers to stop offering health plans, swelling the ranks of the nation's 44 million uninsured.

But bill supporters said it safely insulated employers from unscrupulous lawyers and placed blame on those that made the health care decisions.

Palm Mortuary chief financial officer Roger Kreml said small business owners probably would not rush to drop health care if the bill was passed.

But they might be forced to offer less attractive plans if patients began targeting employers as well as HMOs, he said. Palm, which operates five funeral homes, has about 120 employees enrolled in its HMO plan.

"We're a third party here," Kreml said. "We're not the worker who needs a heart transplant or the medical community. All we did is pay the insurance for the worker."

The House bill now travels to a joint Senate-House conference committee where representatives from both bodies will try to hammer out a compromise. The Senate's version of the bill is more limited; it does not allow patients to sue. President Clinton would then have to sign the bill into law.

Some predict the committee will not reach a compromise, killing the legislation.

Gibbons voted for the bill after pushing for an alternative version that would limit patients to suing in federal court -- for a judgment of no more than $500,000. He said the alternative bill would have better protected employers against frivolous lawsuits. That bill was defeated.

Gibbons then crossed party lines and voted with 68 Republicans who eventually supported the heavily Democrat-backed Norwood-Dingell.

"I came here to do what is in the best interests of the people of Nevada," Gibbons said. "I've voted differently than the Republican leadership many times."

Berkley was a strong backer of the bill.

"I have been a supporter of the patient's bill of rights since before I was elected," said Berkley, a freshman representative. "Stories like Mrs. Victorson's convinced me that this was an important piece of legislation that was worth fighting for."

Las Vegas resident Janice Victorson, 51, has multiple sclerosis, a debilitating disease that throws her off balance, limits her sight, saps her energy and affects movement in her right hand. She has been trying to convince Sierra Health to pay for daily Copaxone injections, at a cost of $950 a month. The drug diminishes her symptoms, she said.

Victorson said she would relish the chance to plead her case in front of an external panel created under the bill passed Thursday.

"I cannot wait for the bureaucracy of this anymore," Victorson said. "I want to fight these HMOs any way I can."

Sierra Health's O'Neill said he was unable to locate the details of Victorson's case Thursday. But he spoke generally about the bill passed Thursday.

"Most people are aware of the HMO horror stories, but they are aware of them happening to other people -- not to them," O'Neill said. "These are very complicated cases. And in fact, the vast majority of Americans are very satisfied with their health care."

O'Neill added that health care costs will increase if Clinton eventually signs the House version of the bill.

"You're also going to see an increase in the number of uninsured Americans," O'Neill said. "Those will be the long-term effects."