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A Referee in Disputes Between Patients, HMOs

A year after its debut, a state agency offers a glimpse of how expanded rights may play out nationwide.


One is a new mother whose infant son requires around-the-clock medical attention. The other is a retired police officer who needs a specialist nearby to help treat a chronic illness.

Like millions of Americans across the country who have had disputes with their HMOs, these two Californians had neither the energy, the time, nor the willingness to pursue a lawsuit. They simply wanted their problems to be fixed.

So Nicole Breslin, 29, of San Jose, and Gerry Goldshine, 47, of Rohnert Park, turned to the state agency whose job it is to hear their complaints and try to do something about them: the California Department of Managed Health Care.

As Congress continues to debate new patient protection bills, experts say it is not the bills' most politically charged feature--the expanded rights to sue--that will directly affect most of the 175 million Americans in private health plans. Rather, the most important element in the congressional debate "is securing the right to a second opinion about your case," said Sara Rosenbaum, a professor of health law and policy at George Washington University in Washington, D.C.

A little more than a year ago, the California legislature established the Department of Managed Health Care to do just that. While 41 other states have enacted laws providing outside review of HMO complaints, the agency serves the country's largest HMO market--23 million members. While HMO complaints are handled by a variety of regulatory agencies in other states--typically, state departments of insurance--the managed health care agency is the only stand-alone agency of its kind in the country. "I have said from the beginning that we would not be impartial, that we would be admittedly pro-patient," said director Daniel Zingale, a former AIDS activist.

Many health policy experts and legislators across the country believe that the California agency offers perhaps the best glimpse of how expanded patient rights may play out for most Americans.

Based on interviews with patient advocates, health care lobbyists and policymakers around the state, there is a broad consensus that the department is largely fulfilling Zingale's pledge to create a consumer agency that is responsive to patients and effective in addressing their concerns. Observers said the agency has responded swiftly to cases that involved medical emergencies, has cut through HMO red tape to end delays in providing care and has quickly resolved misunderstandings between plans and patients. They say the department is a vast improvement on its predecessor, the Department of Corporation, another state agency that handled HMO complaints previously.

At the same time, advocates say there are many patients receiving substandard care whom the department cannot or does not help, either because the cases involve a thicket of disputed facts or because patients haven't presented their case effectively. "We hear the same thing from advocates around the country," said Ron Pollack, executive director of Families USA, a health consumers' rights group based in Washington, D.C., which has been active in the patients' rights debate. "These external review boards are trying to be objective, and many consumers just don't have the capacity to present their case like health plans do."

Nicole Breslin can talk about the department at its best. Last November, Breslin and husband, Christopher, gave birth to their first child, Christopher Liam, a child whose 91/2 pounds belied creeping degenerative muscle disease. Pale and ominously passive, the boy didn't squirm; he flopped. His breathing was uneven, his bones unusually soft. After weeks of testing, and surgery to correct his lung function, the Breslins still had no diagnosis. All they knew for certain, she said, was that their son would need a team of pediatric specialists to ensure his survival.

The new parents assumed their insurance was solid, for they were double-covered: Nicole had a Cigna HealthCare of California policy through her former job, and Christopher had recently enrolled in Kaiser Foundation Health Plan.

But in fact the double coverage proved problematic; an agreement between insurers providing joint coverage prompted the child's transfer from Cigna's care to a Kaiser facility in the middle of treatment. The Breslins couldn't bear the thought of moving their son. "We'd already moved him once, and after all he'd been through, we didn't want to have him poked and prodded and reexamined yet again," she said.

The stalemate put the baby's coverage, and his life, in the balance, the Breslins thought.

Desperate, Nicole called her legislator's office and learned about the health agency's HMO Help Center, which operates a 24-hour consumer hotline.

After reviewing the family's case, an agency lawyer informed the health plans that they could not deny or interrupt coverage because of problems coordinating care.

The boy would be covered, as long as he stayed in the hospital.

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