THE VIRGINIAN-PILOT
Copyright (c) 1996, Landmark Communications, Inc.
DATE: Sunday, May 5, 1996 TAG: 9605010027
SECTION: REAL LIFE PAGE: K3 EDITION: FINAL
SOURCE: ALEXANDRIA BERGER
LENGTH: Medium: 68 lines
LAST JULY, my son was in an accident. After a battle with his HMO, it agreed to pay the hospital, but refused to pay the ambulance service that brought him there, unconscious. It paid the surgeon, but refused to pay the anesthesiologist, who administered anesthesia during emergency surgery.
This is just another refrain from that familiar song ``Reimbursement Havoc,'' by the group Always There For You. I'll bet you can match my stories with some real zingers.
What we're experiencing, is the nation's latest ``emerging'' industry - better known as ``managed care.'' Add to this the influx of entrepreneurs who have figured out how to ``manage'' patient care and manipulate the system while lining their own corporate pockets with green stuff, and you have one of the most lucrative industries to hit Wall Street in a long time.
The managed-care concept has been so successful, it has crept into every form of health care coverage.
For us, the disabled, chronically or seriously ill who generate the need for greater medical and pharmaceutical intervention, medical care at discount prices has proven a disaster. We're seen as a drain on the managed care system, deflecting profit from HMO coffers.
So it is no wonder the current system can easily plunge ``high maintenance'' patients into a financial abyss with no means of rescue. Even insurers who offer the whole medical enchilada at regular prices have picked up the techniques, which are making the discount spinoffs rich. No matter what you pay, somewhere down the line, when you need any kind of advanced medical care, be prepared for a fight.
Recent front-page stories point to a national problem.
The so called ``gag rule'' or ``disparagement clause'' currently found in many HMO physician contracts (which the industry denies exist) explicitly prohibit doctors from criticizing the managed-care firm and from telling their patients the full range of treatment options available.
Violation can result in physician termination. Therefore, physicians have faced becoming agents of the insurance companies, rather than patient advocates. Angry and frustrated, the American Medical Association and other medical groups have begun openly fighting these policies with public awareness campaigns of their own.
But, according to statistics, some 14,000 people a day are still signing up for managed care - in spite of the possibility that subscribers may have to change their primary-care physician, and have limited choice of specialists, hospitals, medications and treatments. For chronically or critically ill, managed care has the power to ``total'' a patient, like a wrecked car, when care becomes uneconomical.
Yet the industry has already made it apparent that not only are the disabled and chronically ill expendable, but all patients and physicians as well - patients, because for each one who drops out, there are thousands waiting to sign up. Physicians, because without managed care, their practice may drop dead, should they be blacklisted or bypassed by insurers.
The only solution is legislation, which has the real power to curb the managed-care profit motive, while protecting patients' rights, and allowing physicians to practice medicine. Otherwise, instead of singing ``Reimbursement Havoc,'' we'll all be whistling ``Dixie.''
A footnote: One of the most handicapped-accessible places to go in Hampton Roads is the Chrysler Museum. Use the side entrance, and visit the Museum's Cafe, Palettes, on Mother's Day for a $12.95 brunch. Call Lynne Priest at 664-6268 for more information, or if you are fluent in ``signing,'' volunteer. They need you! by CNB