The politics of health care

Martin Kuz

Sunday, May 7, 2000 | 8:24 a.m.

Anna Gonzales found out she might have Hodgkin's disease during an emergency room visit in December. She began chemotherapy exactly five weeks later under a plan of care dictated by her health maintenance organization.

Gonzales says her HMO took too long -- and caused her too much anxiety -- in approving the course of treatment. Officials with the provider insist the care she received qualifies not only as efficient, but lightning fast.

So who's right? Both sides, it seems, in the exasperated age of managed health care.

Gonzales' case represents a small clash in the ongoing war over whether HMOs offer timely treatment. One HMO industry observer in Las Vegas calls her allegations "a classic example of the frustration that drives the politics of health care."

Jim Wadhams, a longtime attorney involved in health care matters, went on to say that the Gonzales story illustrates the ever-widening chasm between patients and insurers on the definition of quick care.

"The HMOs have assumed some responsibility for the timing and selection of the kind of treatment we get, so we have a very obvious and visible place to put the blame when there's unhappiness about the treatment," Wadhams said. "There's an obvious difference of opinion on what's best."

Criticism of managed care providers holds that, among other flaws, HMOs too often reject doctors' requests to run vital medical tests, impede patient access to treatment and deny care outright.

Widespread discontent with HMOs has spurred federal lawmakers to pursue passage of a so-called patients' bill of rights, a measure that would ratchet up the accountability of managed care providers. Democratic leaders, including Sen. Harry Reid, D-Nev., support a proviso that would allow patients to sue an HMO if treatment is denied or substantially deferred.

Gonzales revealed her story last month in Las Vegas during a public hearing on HMOs attended by Reid, the Senate's second-ranking Democrat, and Sen. Byron Dorgan, D-N.D., chairman of the Democratic Policy Committee. Hoping to bolster their argument for health care reform, Democrats have organized a series of hearings across the country to gather patients' anecdotes of HMO woes.

A 28-year-old mother of two who lives in Henderson, Gonzales testified that her provider delayed her treatment for Hodgkin's disease, a potentially fatal condition marked by progressive enlargement of the lymph nodes, spleen and liver.

Gonzales first learned she might have the illness when, days after noticing a lump on her neck, she checked into the Sunrise Hospital emergency room Dec. 29. A doctor examined Gonzales' chest X-rays and told her the tumor could be a symptom of Hodgkin's disease.

Gonzales said she went to the emergency room out of a sense of desperation precipitated by her HMO. She accused the provider of subjecting her to a three-day gauntlet of doctor referrals after she visited her primary care physician Dec. 26.

The referrals, Gonzales claimed, were a bureaucratic endless loop. She said her primary physician directed her to visit a general surgeon, who would perform a biopsy on the neck tumor. Yet when she called the general surgeon's office, Gonzales said, she was instructed to first see an ear, nose and throat specialist.

Gonzales said she called the specialist's office, but was informed she would not be examined until after obtaining a referral from the general surgeon. She reportedly called the general surgeon's office back, only to be told that such a referral could not be given -- despite the general surgeon's earlier recommendation that she go to the specialist.

A worker in the general surgeon's office, Gonzales said, suggested she get a referral to the specialist from her primary physician. She tried, but the primary physician pointed her back toward the general surgeon, she said. At that point, an aggravated Gonzales opted instead for the emergency room.

The apparent runaround proved a prelude to subsequent problems, Gonzales said. She alleged that she wound up slogging through three more referral swamps in arranging a CAT scan, a visit with an oncologist and a bone marrow biopsy. The delays ranged from several hours to a few days, she said.

Gonzales also said that on the day she went to the general surgeon for insertion of a catheter in her chest -- a procedure that precedes chemotherapy -- she was abruptly referred to a cardiovascular surgeon. Complications with placement of the catheter later resulted in a three-day postponement of Gonzales' first chemotherapy session.

"I know that I will be cured if I receive aggressive, early treatment," Gonzales said at the hearing. "But the only thing that my HMO has been aggressive about is collecting premiums and co-payments."

The Sun and at least one other media outlet reported on Gonzales' testimony without seeking response from her HMO, Health Plan of Nevada. The provider, a subsidiary of Sierra Health Services Inc., covers 200,000 Nevadans statewide.

In a recent interview Dr. Anthony Marlon, chairman and CEO of Sierra Health, blasted the media coverage as one-sided. He portrayed Gonzales' cycle of treatment -- even allowing for the adjustment of the chest catheter -- as "absolutely good care."

"This was the absolute fastest possible care one could possibly receive. It can't be done any faster. And in most instances, the process would take two or three months," he said.

Marlon wrote to the Sun to protest an April 18 editorial that he felt distorted the circumstances of Gonzales' treatment and questioned the speed of the care she received. The editorial charged that the HMO "shuffled her from doctor to doctor" and that Gonzales "spent a lot of her energy battling her HMO instead of fighting her disease."

In his letter Marlon asked, "Does a newspaper have any obligation to the facts? Does it have the right to make any allegation to advance its position? Does it have any obligation to its readers and to find out whether what it prints is true? In the case of the Sun, it appears the answer is a resounding no."

The letter provided a timeline of Gonzales' treatment, starting with her Dec. 29 emergency room visit. The CAT scan was performed the next day and an oncologist examined her Jan. 4. After a bone marrow biopsy on Jan. 7, Gonzales received the diagnosis of Hodgkin's disease a week later.

Health Plan approved a MUGA scan -- a test that determines if a person's heart can withstand the rigors of chemotherapy -- on Jan. 21, and three days later Gonzales underwent the procedure. The catheter was inserted Jan. 26 and replaced three days later. Chemotherapy began Feb. 2.

"I guess if you own and control a newspaper you can avoid the nagging problem of determining 'truth,"' Marlon wrote.

"There are things that may go wrong in the practice of medicine. There are things that may go wrong with how we provide insurance coverage... (But) I strongly believe that as physicians we try to do the right thing!"

Gonzales takes a dimmer view. She looks back on the 38 days that lapsed between her initial visit to the primary physician and the start of chemotherapy as the most agonizing period of her life. Only dogged hectoring of doctors and Health Plan personnel kept her case from further bogging down, Gonzales asserted.

"I think they thought, 'Either get this crazy woman away from us or take care of her,"' she said, managing a laugh.

Gonzales understands time was needed for lab tests and other procedures. But she faulted HMO officials for creating the referral madness and for harboring a blase attitude toward a patient with a life-threatening malady.

"Who are they to say that you can wait 30 days if you're that ill?" she said. "There's a difference between having a cold and having cancer. If you wait 30 to 40 days, who knows what can happen? The earlier the treatment starts, the better your chances (for recovery)."

Yet both health care reform advocates and physicians regard the five-week time frame in Gonzales' case -- the alleged referral snafus notwithstanding -- as reasonably quick treatment. Their opinion, however, carries a caveat: "quick" is a relative term in the world of managed care.

Ruth Mills serves as coordinator of the nonprofit Nevada Health Care Reform Project. The statewide coalition, comprised of representatives from 53 organizations, lobbies lawmakers on state and federal managed care issues.

Mills attended the Reid-Dorgan public hearing, where dozens of people recounted their run-ins with HMOs. She has heard so many similar tales of thwarted or deferred care that she believes providers now benefit from lowered expectations of how fast a patient can pass through the HMO system.

"If a person has cancer or another serious disease, (38 days) can make a lot of difference on the effect of treatment. From that point of view, that's an unreasonable amount of time," Mills said.

"But the way the health care system is so messed up, (38 days) probably wasn't bad in this case. That still doesn't make it right."

As chief of oncology at University Medical Center and a staff member of the Las Vegas clinic Cancer Consultants, Dr. John Ellerton has treated hundreds of Hodgkin's disease patients during his career.

According to Ellerton, Gonzales likely began receiving chemotherapy about as swiftly as can be expected by the standards of managed care. Nonetheless, he contends, what providers consider speedy care can appear sluggish compared to pre-HMO days.

"I would say that from my side of the table -- in terms of organizing investigations and treatments -- it was faster 20 years ago. If I wanted to, I just sent a patient for the treatment that I felt was necessary," he said.

"Things are more of a hassle nowadays. Now you're having to get approval for everything, and that makes it more difficult to push patients through."

Even when patients receive treatment as quickly as they did two decades ago, Ellerton said, the paperwork, referrals and other managed care red tape they must knife through fosters a perception that the process has slowed.

The bureaucracy also fosters profound irritation.

"As a patient, if I was diagnosed with a serious disease, how long would I want to wait to start treatment? About two days is all I could stand," he said.

Some cases tumble through the cracks, Marlon conceded, and there are occasions when patients suffer untimely delays.

But Marlon remains adamant that Gonzales, who has been treated by no fewer than eight physicians, received the best care Health Plan provides. He maintains that what Gonzales depicts as unwarranted delays are, in fact, the normal and necessary periods of time that pass between administration and analysis of lab tests.

Marlon also said that Gonzales' medical file includes only one notation regarding her claims of difficulties obtaining a referral.

"Medical care is complicated. Sometimes there are outcomes you don't like, sometimes you do things wrong. Let me tell you -- this isn't one of those times," he said.

"If you went to the Mayo Clinic you couldn't get this done any faster," he added.

Gonzales works as an office assistant at the Las Vegas medical clinic of Dr. Frank Nemec, past president of the Nevada Medical Association. It was Nemec who urged Gonzales to go straight to the Sunrise Hospital emergency room after her apparent referral troubles. He also persuaded Gonzales to tell her story publicly.

A Reid spokesman, responding to Marlon's charge that the senator's staff never called Health Plan to verify the version of events related by Gonzales, said Nemec provided adequate corroboration.

Nemec, noting that HMOs are unlikely to keep a running record of a patient's complaints, said he watched Gonzales spend the better part of three workdays chasing referrals that went nowhere.

In that respect he challenges Marlon's comment about the Mayo Clinic, and makes a point about the despair a patient with a serious illness feels when traversing the HMO maze.

"It's cruel to keep a patient waiting and talking on the phone," Nemec said. "People at the Mayo Clinic are never doubting that they're going to get the care they want. Every day, Anna doubted whether she was going to get the care she needed."

That sort of distress, more so than the actual rate of care, can deepen disdain of HMOs, Wadhams said. Addressing the Gonzales case in broad terms, Wadhams pointed out that people always will champion a mother suffering from Hodgkin's disease over a faceless insurance company.

"Is Dr. Marlon right? He may be. But that still doesn't change the sympathies. And that's where HMOs find themselves," Wadhams said.

More to the point, Wadhams suggested a fed-up Congress soon may shove providers toward a revamped managed care system that resembles one of old.

Wadhams predicts a return to a health care philosophy in which HMOs ante up a fixed amount to pay for a particular test, treatment or surgery while leaving the patient to pick doctors and make appointments.

"Health care companies are going to retool themselves. They're going to say, 'Go where you want, go when you want -- we're only going to pay this much,"' he said.

Nemec added that patients' constant hammering of insurers has compelled providers to gradually loosen their sometimes oppressive restrictions on physicians.

Obtaining approval for lab tests and ramming critical care cases through the HMO system have become nominally easier the past couple of years, he said.

"We're already seeing HMOs being kinder and gentler than they have been. They're realizing that some of the things they've done in the past will no longer be tolerated," Nemec said.

Gonzales, for her part, has more on her mind than HMOs as she endures four-hour chemotherapy sessions twice a month. So far the treatment has worked, shrinking a cancerous mass that at one time covered two-thirds of her right lung.

But recently separated from her husband, Gonzales still worries about living long enough to see her children, Michaela, 4, and 1-year-old Jacob, grow up. The burdens of overcoming a deadly disease, raising a family and working full-time makes her seethe at HMO officials touting the speed of her treatment.

"It's hard to explain how I feel about them because I'm so angry," she said. "They did what they did, and it was wrong. I just have to try to move on."

Martin Kuz is a reporter for the Sun.

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