Health Maintenance Organizations

A highly unusual battle erupted in a San Diego courtroom Friday, with parents of a severely premature baby seeking to force healthcare giant Kaiser Permanente to move their son to a better-equipped hospital in hopes of saving his life. In the morning, Superior Court Judge Kevin Enright gave Kaiser's San Diego hospital 24 hours to transfer 7-week-old Andrew Balaka-Long to a higher-level neonatal intensive care unit outside the Kaiser network.

Many Californians enrolled in healthcare plans are receiving inadequate preventive care, a government report said Thursday. The eight largest plans in the state fail to ensure that their 12 million members are sufficiently tested and treated to prevent and detect major diseases and reduce unnecessary expenses, according to the California Office of the Patient Advocate's report, called the Health Care Quality Report Card.

A nonprofit health plan that has served the poor and elderly of Southern California for more than three decades will be sold to rescue its parent foundation from bankruptcy. Watts Health Foundation Inc. has decided to sell its UHP Healthcare HMO for $30 million to a for-profit managed health company, foundation officials said Tuesday. The plan's 80,000 members would keep their coverage and should see little change, they said.

About 1 million Californians with limited English proficiency could receive lower-quality healthcare from their HMOs because of language barriers, according to a UCLA study released this week. Of the 9.4 million adults enrolled in HMOs in 2003, the study found that about 10% of clients -- most commonly native speakers of Spanish, Chinese, Vietnamese and Korean -- reported not being able to speak English well or at all.

WellPoint Inc., the nation's largest health insurer that covers about 1 in 10 people in the U.S., fared the worst among its peers in a survey gauging how quickly HMOs process and pay claims to doctors. The analysis, released Thursday, examined 5 million line items in claims submitted by 7,000 doctors to health insurance companies using a computer-based payment system sold by Athenahealth Inc., which compiled the study. Indianapolis-based WellPoint, which covers 34 million patients in the U.S.

Rate increases for health maintenance organizations are set to decline in 2007 for the fourth consecutive year, but still create challenges for employers, according to a report released Tuesday. Preliminary figures indicate that HMO rates will jump 11.7% next year, down from initial estimates of 12.4% in 2006 and 13.7% in 2005, said Hewitt Associates, a consulting firm based in Lincolnshire, Ill.

In the first sanction of its kind, California's top HMO regulator fined Blue Cross on Thursday for illegally canceling a woman's medical policy because she did not disclose corrective surgery she had 23 years earlier. The $200,000 fine might not be the last resulting from the state's investigation of allegations that insurers dump sick policyholders to avoid paying claims, said Cindy Ehnes, director of the Department of Managed Health Care.

Under mounting pressure from consumer advocates, the state's HMO regulator plans to introduce a rule that would make it harder for health insurers to drop policyholders after they get sick. Cindy Ehnes, director of the Department of Managed Health Care, is expected to propose that insurers be required to maintain coverage unless they show an individual lied about his or her medical condition to obtain it.

California consumers continue to pay lower premiums with health maintenance organizations than with other forms of health insurance. But the state's HMOs may be losing their ability to contain prices and are no longer much cheaper than their counterparts elsewhere in the country, according to a report released Wednesday.

California regulators proposed prescription drug protections for HMO members Tuesday, describing the rules as the nation's first to mandate broad coverage of medically necessary medications. Although they hailed the thrust of the draft regulations, patient advocates said they feared vague language could allow health maintenance organizations to raise drug co-payments beyond the reach of many consumers, contradicting the spirit of the 2002 law the rules are supposed to implement.