HMO Hostages? Medical organizations, patients debate ‘John Q.’s‘ reflection of reality

Kirk Baird

Monday, March 4, 2002 | 8:20 a.m.

In recent years Health Maintenance Organizations (HMOs) have become the frequent subject of water cooler and e-mail humor:

Question: How many nurses does it take to change a light bulb in an HMO?

Answer: Only one, but they need a pre-authorization before it can be done.

But in the recent film "John Q.," HMOs have gone from being a punchline to cold-hearted villain.

In the movie, John Q. Archibald (played by Denzel Washington) is the Everyman faced with a financial and moral crisis when his son requires a heart transplant to live.

The illness catches the family off guard and John assumes his insurance will cover the cost of the procedure. He is horrified to learn, however, that as a part-time employee, his coverage was reduced to a second-tier level, meaning the maximum coverage he can receive is $20,000 about $230,000 less than what he needs.

John pleads for help from the HMO provider, with the staff and surgeons of the hospital where his son was admitted, and to anyone who will listen. He discovers that without the money or insurance, nothing will be done.

John is forced to sell most of his possessions including his car and wedding ring but he is unable to come up with nearly the amount of money the hospital requires before it will place his son's name on the organ-donor list.

In a fit of despair from the bureaucratic runaround he's weathered, John takes patients and hospital employees hostage in the emergency room, including the heart surgeon who refused to perform the surgery, until his son is placed on the list.

Much of the film is pure Hollywood especially the hostage storyline but the film's demonizing of HMOs and the health-care system in general seems to have resonated with many Americans. The film opened at No. 1 three weeks ago.

But is the film plausible? Could a John Q. scenario really happen?

Karin Huffer knows from firsthand experience that it can.

A school counselor at Washington Opportunity Junior High School in Las Vegas, Huffer has been an employee for the Clark County School District for 23 years. Her employment includes numerous benefits -- including full medical coverage. Huffer put the coverage to the test in 1999 after being diagnosed with breast cancer.

Her condition required a specialized life-saving surgery which, at that point, was not available in Nevada. She then made arrangements with a surgeon in Santa Monica, Calif., and with the authorization of her HMO, Huffer had the operation.

Soon after she received a bill for $17,000. The HMO had approved the surgery and the surgeon, but had not given the OK for the operating room where the procedure took place.

"I assume if they authorized me to have the surgery they authorized the place for me to have it," she said.

Nevertheless, the bill for use of the operating room was not paid by the HMO. The group accused the hospital of overcharging for what it considered "reasonable and customary" care.

"Instead of working with me, they played games and I ended up being stuck with the bill," Huffer, who is in her 50s, said.

Two years later she is still paying off the surgery -- although at a partial "pity reduction" from the hospital.

"It isn't like I just wrote a check for it," Huffer said. "This has been a big loss for me, at a time when I couldn't afford it."

Health-care crisis?

While Huffer's story is not as dramatic as that depicted in "John Q.," its authenticity makes it every bit as alarming.

Dr. Rudolph Mueller, a physician in Jamestown, N.Y., witnessed firsthand "John Q."-type cases, where patients were denied life-saving care because they either couldn't afford the insurance deductibles for surgeries or medicine or, in some cases, had no medical coverage at all.

In one day Mueller saw a patient admitted to a hospital because the patient had quit taking heart medication because he could no longer afford it.

Another patient with a life-threatening illness didn't have health insurance, so Mueller provided him with free samples of medication the drug companies had shipped to the doctor.

One dying patient Mueller had referred to another physician was horrified to hear the doctor tell her, "You have the money to pay me, don't ya?" That doctor wouldn't see the patient for the following six weeks because she didn't have insurance or the financial means to pay him.

Those stories prompted Mueller to write the recently published book "As Sick As It Gets: The Shocking Reality of America's Healthcare, A Diagnosis and Treatment Plan" (Olin Frederick Inc., $22.95).

"I think the (health-care) system is majorly broken and very sick," Mueller said. "It's a system about money, and decisions are based on money rather than taking care of people. This is not the way you want a health-care system to work."

Representatives of Nevada HMOs, however, said "John Q." is pointing the finger in the wrong direction.

Peter O'Neill, a spokesman for Sierra Health Services Inc., Nevada's largest managed-care company with 350,000 members, said it is not HMOs that are to blame for lack of coverage, rather the employers who select which plan to offer to their employees.

In the film, for example, it is John Q.'s employer who had reduced his benefits -- not the HMOs.

"It's an employer's issue," O'Neill said. "We have the coverage and encourage the employers to purchase it."

Also, HMOs are not allowed to offer such a low-maximum payment as the $20,000 for a transplant as fictionalized in the movie.

"Our transplant maximum is significantly above what's listed in the movie," said Todd Meek, chief executive officer of NevadaCare, the second-largest HMO in the state with 85,000 members.

"And ... given the constraints that NevadaCare has in place, that will not leave an individual in the situation (that) is portrayed in the movie."

In other words, Meek said, a patient wouldn't be kicked out of a hospital for lack of coverage.

"It's certainly easy to lay blame or create an antagonist for a film that's 90 minutes or longer ... it's a better story that way," he said. "You couldn't sell a lot of tickets to a film that shows HMOs and all the good things that our industry does, such as improving access to care."

Time for a change

Ruth Mills has made it her mission to bring about health-care reform to Nevada, ever since her daughter-in-law required a routine, pain-relieving surgery nearly 10 years ago, but ran into problems with her medical insurance.

Her daughter-in-law hadn't been employed long enough to qualify for medical coverage. When Mills offered to pay cash for the procedure, the insurance company representing the doctor refused the money, saying it only dealt with payments from other insurance companies.

So Mills' daughter-in-law was forced to limp along on medication for two weeks until she was eligible for medical coverage and could have the surgery.

"That sparked my curiosity," Mills, a retired Las Vegas teacher, said.

She then began investigating health care. As she dug deeper she uncovered more stories from others who had problems with their health-care coverage.

Reform Project

Mills eventually created the Nevada Health Care Reform Project in 1997, a patients' advocacy group based in Las Vegas.

As director of the Health Care Reform Project, Mills took a grass-roots approach to bringing about change, lobbying local and state officials on creating a neutral organization to, among other responsibilities, listen to and investigate patient complaints and concerns with HMOs.

"The system is so complex today people don't know how to navigate it -- even if they're in an HMO," Mills said.

In late 1999 Mills received her wish when Nevada's Office of the Governor for Consumer Health Assistance was created.

Essentially the Consumer Health Assistance agency makes sure all the members in a health-care dispute -- HMOs, doctors, hospitals and the patients -- are playing fair. The office received around 3,400 calls last year, of which 1,600 were investigated.

"The others were resolved by phone calls -- and not every (complaint) do we resolve monetarily," said Valerie Rosalin, a Las Vegas registered nurse who was appointed director of the office in October. "But we saved the consumer some $1.2 million by getting treatments and facility (bills) paid" by managed care companies or write-offs by physicians.

The office, which offers its service free of charge to Nevada residents, typically resolves medical-billing disputes costing from a few hundred to a few thousand dollars, although the fees can sometimes be more.

"We had one case that we won $63,000 (for a patient) that was a write-off," Rosalin said. "It involved a doctor, a hospital and wage-replacement. We made an investigation along with the insurance company."

Although she has not seen the movie, Rosalin acknowledged there are a few cases as dramatic as that in as "John Q." out there, and that HMOs are essentially a business and need to make a profit to stay afloat.

But Rosalin also said she believes managed care is still doing a service to the public that is often overlooked -- even by an overly cynical Hollywood.

For example, HMOs insist on routine checkups for customers with diabetes or heart problems. That precautionary care typically wasn't available before HMOs, she said.

As for to the film's ultimate question -- whether everyone deserves equal access to health care -- Rosalin said it comes down to a philosophical conundrum:

"Is health care a privilege or a right?" she asked. "And how do you balance a privilege or a right? I don't know."

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