A Referee in Disputes Between Patients, HMOs

The department also has broad powers to intervene if it concludes that there's been a major violation, and Zingale has not hesitated to use them. Among the department's significant actions in its first year:

* In May, 2000, Zingale decided to fine Kaiser Permanent $1 million for failing to provide adequate care to a 74-year-old woman who later died of complications from a ruptured aneurysm. Kaiser is appealing the fine.

* In February, the department forced PacifiCare of California to pay overdue claims it owed to doctors and others in its networks.

* In May, the department took over daily management of Maxicare Health Plans, a statewide HMO with some 275,000 members, which is having severe financial problems.

For all that, there are some patients who feel the department has failed them. Gerry Goldshine is one. Goldshine has Crohn's disease, a chronic affliction in which the body attacks its own intestines, causing intestinal blockages, severe stomach cramps, disabling diarrhea and other symptoms. "Some days are better than others, some months better than others," Goldshine said. "But you need to have a gastroenterologist you can see when the disease flares up."

About the time the Breslins were haggling with their insurers, Goldshine learned that visits to his longtime gastroenterologist would no longer be covered; the doctor had terminated his relationship with Goldshine's health plan, PacifiCare of California.

Goldshine called customer service and asked for a replacement. He was referred to a doctor in San Francisco--more than an hour's drive from his house.

"That's just too far to go," he said. "To be honest, all I really wanted was for them to say, 'Go ahead and see your regular doctor, and we'll cover you until we find someone else."'

No such luck. By mid-March, frustrated with the delay, Goldshine called the HMO Help Center. A case officer contacted the health plan a few days later, and PacifiCare assured him that it had a gastroenterologist with an office in Petaluma, near Goldshine's home.

But when Goldshine called the Petaluma office, he learned that the doctor would not be seeing patients there for a couple of months. Even then, office hours were unpredictable, he said. "I was told that the doctor would be spending only two weeks a month in Sonoma County, and they couldn't tell me in advance which weeks those were," he said.

And there the matter stands. Though the department hasn't officially closed the case, it has not taken any action either, and Goldshine is now paying out of pocket to see his original doctor. "I was a police officer for 20 years," he said, "and if I let a case drop like this, I would have been fired."

Asked about the case, Zingale acknowledged that the patient is in a tough spot. "If at all possible," he said, "we should be able to get people in to see the doctors they want to see."

At the same time, he said, Goldshine's situation has problematic elements: Namely, there was no medical emergency; and, in the end, there was no clear violation of state rules governing HMOs.

In fact, patient advocates say, it's often difficult to pinpoint violations, even when it appears likely that a patient is receiving substandard care. "The department is relying at least partly on the health plans' account of what happened to patients," said John Metz, chairman of the California Consumers Health Care Council, a nonprofit advocacy group in Oakland, "but they have no way to verify the facts provided by the plan."

The result, said Metz, is that some cases go in favor of the HMO because it's not clear what happened. "If the department takes no action, that's a decision in favor of the plan," he said, "and often we think that's the wrong decision."

Barbara Reagan, chief of the HMO Help Center, acknowledged that it's not always clear from reviewing the information consumers and plans provide what exactly happened. "We cannot get involved in every 'he said/she said' case if there's no evidence of a violation" by the plan, she said. The agency is required by law to take action on complaints in 30 days.