HMO

[KDK513]

You may have recently heard on your local news of someone who has had a spinal cord injury whose friends are having a fundraiser to pay for outpatient physical and occupational therapy. You may be surprised to learn that this is not to supplement current therapies paid for by health insurance. This is because HMO's have established a NEW STANDARD OF CARE that limits outpatient therapies to no more than 20 or 30 PT sessions a year regardless of your injury or current progress. OT may be limited to 15 or 20 therapy sessions a year. If you have a serious injury , well that is just too bad.

We appealed this recent change in our coverage and have 3 almost identical denials in our file. The appeal process was a farce. Medical necessity, continued improvement in ambulation and motor function, Doctors' letters, Therapists' letters, documentation in support of additional therapies was nothing compared to "Our Contractual Agreement". The farce lies in the fact that no other choices existed.

With great empathy an employee of our HMO explained that the decision to limit therapy coverage was made by the Benefits Director of our Group to save money. Herein lies the final insult. The reimbursement rate our HMO provides is $45 an hour per therapy. (HUGE SAVINGS!) hmmmm... Guess what! I am not permitted to pay that same rate out of pocket per their contract with the providers here in town. Our rate is 4X that, unless we participate in a group therapy, which is less expensive.

My husband's onset of paralysis was in December 1999. His inpatient rehab lasted 3 weeks. His Outpatient therapy consisted of 3PT and 3 OT sessions a week for a couple months. We continued throughout the rest of the year with 2 PT a week. Our coverage changed this year to include no more than 30 PT and 20 OT and 20 Speech therapies annualy. We used all the PT in short order and none of the OT or Speech. I am supposed to be overjoyed that we no longer need pre approval.

His paralysis was at the T4 level, incomplete. He continues to improve and gain return and hopes to ambulate with a cane by the end of the year. Should we also begin the discussion about maintenance therapy and aging with SCI, changes in our bodies that require additional therapies?

Has anyone had a similar experience with their HMO with a better result? Any suggestions how to proceed? Does anyone share my concern that future treatments for SCI patients are SUBSTANDARD? I am willing to fight the good fight; however, an individual does not have any clout. I know from experience. There is indeed strength in numbers. Any groups out there ? Kathy

[This message was edited by KDK513 on August 15, 2001 at 07:31 AM.]

[rosebud]

KDK513
Our experience is about the same. Maybe the propsoded legislation for HMOs will improve our situation.

[KLD]

This is why I would never have an HMO...fortunately my employer offers a choice of insurances, and I am willing to pay more in my share of costs to be sure I can get more what I need without a 3rd party (usually a clerk) telling me yes/no. "Mangled care" is fine for well check-ups and common illness, but is generally not very good for those with disabling injuries or chronic illnesses.

Is your husband by any chance a military veteran? If he is, he should go immediately to his closest VA SCI Center. It will be worth the effort.

[KDK513]

KLD, thank you for the suggestion. My husband is not a vet. We are fortunate that our coverage was better the first 12 months following his paralysis. I cannot imagine where we would be had this happened more recently. For all the progress that has been made understanding and treating SCI it seems the quality of life should be far better for those injured in recent years than I have witnessed.

I realize that everyones recovery is different, but it is interesting to note the remarkable recovery made by the young man injured playing football at Penn State. In addition to receiving appropriate treatment while still on the field, the intensity and frequency of PT he was fortunate to receive far exceeds the current Standard Of Care.

I am aware that studies have been done to measure outcomes of more intensive Therapies (OT, PT, and speech) for those with traumatic brain injuries. I do not know the results of these studies or if any have been done for SCI. Kathy

[Sue Pendleton]

I'm with KLD about HMOs and am thrilled that my husband and I are almost over insured in all put home care but even we are now held to 50 PTs and 25 OT a year on our primary insurance.

There is one thing you can do and that is report any substandard care or denial of service to your state's Insurance Commissioner. The number should be in the blue state pages of your telephone book. Most states do rate insurance company policies and HMOs do watch these numbers carefully. You can also write or go see your US Congressman for your district.

If you can afford the extra time, some PTs or PTAs have been known to work after hours privately...

[KDK513]

Sue, thank you for your reply. I sent an e-mail to our Congressman asking for any reference he could provide to current legislation that would apply in this case. Someone in his office responded with a site that I could not access. (I later found the info. I needed on my own) Prior to this I had contacted the State of Ohio Department of Insurance by phone and was informed that there was nothing wrong with this coverage and that an HMO could essentially do anything they wanted. After continued denials from our HMO and the final decision handed down from the appeals board I am ashamed to say I ran out of steam and decided to save myself some time and further disappointment at simply a higher level.

I am gearing up again, but am going for a different approach and would appreciate any suggestions how to proceed. I thought I would request the specific clinical review criteria upon which the plan relied in reaching its decision to limit therapy in this manner. I will need to begin a new appeals process so thought I would ask if it would be possible to transfer our current OT and Speech therapy coverage to PT which is what he needs. Does this sound valid to you , or are you of the opinion that we should begin again with our original appeal?

I will also write to our Congressman again, this time a personal letter. I should have done this initially as we are Parishioners and his wife and I used to volunteer at school together. It is time to start using what little influence I may have. I can be a real pest when necessary. I just got tired of the constant battles and needed a break. I'm back, as they say, and ready to begin again. I know it's much bigger than me, but I can't be passive and wait for things to change. Any more suggestions out there? Kathy

[Wise Young]

I spent part of Saturday afternoon with the President of the NJ Medical Society, Congressman Pascarelli of New Jersey, and several legal experts while they were waiting for a television interview. It was quite an educational wait. What I learned was that the Patient's Bill of Rights is fatally flawed in three respects:

First, apparently the Norwood amendment rsulted in a rewrite of many key provisions in the bill and now has contradictory language. The opinion of most of the legal experts is that the bill will supercede existing state protections for patient's rights. So, for example, New Jersey has already passed its own Patient's Bill of Rights that is widely regarded as the most progressive and protective of patient's rights. Although the first sentence of the bill said that it does not supercede state mandated protections, the second and third sentences indicates how it can do so. Both Republicans and Democrats in this state believe that the bill amounts to a protection of HMOs against state mandated patient rights.

2. A review board first must arbitrate the complaint. That is fine but the bill stipulates that boards are supposed to decide whether a complaint goes to court only if the HMO is determined to be *the* and not *a* cause of injury and that the HMO is only liable if it does not follow its own rules or standards that they set for care. In the opinion of the experts, this sets a very high legal standard and a very low care standard which would make a successful case virtually impossible. In other words, if the board determines that a doctor is even partly at fault, the HMO must be excluded from the suit and the HMO are free to define their care standards and they are not as fault if they meet the standards that they themselves set.

3. There is a cap on awards and class action suits are forbidden. There is not only a cap on damages and punitive awards but class action suits (i.e. groups of patients getting together to sue) are not allowed by the bill. Because HMO's stand to make many millions, even billions by enforcing certain rules, they can afford to lose a couple of $1.5 million suits and the cost of individual suits is too low to force behavioral changes of the HMOs.

While I am not in favor of lawsuits in general, it seems that this bill really does amount to a bill to protect HMO's rather than patients.

http://www.cnn.com/2001/ALLPOLITICS/...cts/index.html

Wise.

[KDK513]

Anyone know where we can get an adaptable slingshot so the SCI community can strike a blow at the mighty HMO?

Sigh! One more hurdle to go! Kathy

[Sue Pendleton]

KDK, this is way out of my territory but if you can ask for a case manager through your HMO, do so. This is one person who coordinates care. That person might, with I am sure stringent-this is a one time, 1 person only-thing, allow you to move your OT/speach to the PT column. If your husband is close to being able to walk with canes or a walker this will drastically decrease the HMOs future expenses on your husband. SCI who can walk even a little are normally able to deal with bowel and bladder without all the expensive equipment and expenisve antibiotics and drugs like Ditropan XL (which the active military hospitals have yet to approve for everyone).

Appeal to their sense of greed. And defintely keep your congressman in the loop. But also be prepared to buy home equipment to keep a good program going. If you can find a therapeutic pool nar you this will help his walking immensely. Try calling your nearest arthritis association and ask for the nearest "super heated pool". You want something over 92 or 93 degrees if possible.

[Sue Pendleton]

I agree with you about lawsuits, Wise. I feel they are basically forced on some unknowing people by ambulance chasers. Of course everyone wants a couple million dollars, they just don't see what it does to the system. Malpractice is something that is, I believe, fairly rare at a point where it actually hurts patients that are not in long term care facilities.....those are another case.

The minute I saw Senator Frist support the Norwood thing I figured it had to be bad for patients. And reading the fine print, I was right. He should not be allowed to vote on such issues unless he turns in his license to practice for the duration. He should be educating senators about all the issues and instead has become a mouth piece for the HMO companies.

I think we will see another turn around like we did last year with Medicare. They shortened the number of outpatient visits and more elderly who would have gone home wound up in nursing homes costing Medicare a ton. That move was hoped to save a lot of money.

We are very quickly heading towards socialized medicine and that does not work except in smaller countries where high taxes are the norm and all the citizens pretty much agree on what heroic efforts are and all tend to use the well care part of their health insurance first. People also get hit in some countries with a higher hospital bill than others even if a wreck was not their fault solely because they were not wearing seatbelts at the time. To really socialize and make it work you need one group of people who all agree on what good health care is. America was built on our differences and pulling those differing parts together to build great things. But a health care system will not be one of them.