Tuesday, August 03, 1999

Surgery approval becomes a battle

HMO for seniors balked at paying

The Cincinnati Enquirer

        Middletown resident Nora Madden found out the hard way how tough it can be to fight an HMO that doesn't want to pay for an operation.

        The 78-year-old woman, who has a long history of medical problems, originally was scheduled for “minimally invasive” cardiac bypass surgery on May 5. But the operation was delayed more than two months, essentially because Mrs. Madden lived in the wrong county.

        Mrs. Madden's Medicare HMO — the Senior Advantage plan run by Anthem Blue Cross and Blue Shield — repeatedly refused to pay for her surgery, claiming first that it was experimental and then that the surgeon wasn't part of the health plan's network.

        Charles Madden, a son who lives in Texas, went to war. He pursued several appeals, even enlisting Mrs. Madden's surgeon to drive to Columbus to argue. .He wrote letters to senators. He called the media.

        The Madden family is hardly alone in its experience. Two national surveys released this week reported increasing frustration with managed care health plans among doctors and patients.

        A Kaiser Family Foundation report found that 87 percent of doctors surveyed said their patients had experienced some type of denial of coverage in the last two years. Meanwhile, the National Committee on Quality Assurance found 26.5 percent of consumers had trouble getting care they needed, including difficulty seeing a doctor they liked and getting referrals to specialists.

Local frustrations
        In Cincinnati, managed care frustrations have popped up in several ways:

        • More area doctors are talking about forming unions.

        • Two psychologists recently decided to stop accepting managed care contracts.

        • Several independent pharmacists have been locked in a contract fight with ChoiceCare/Humana.

        • Anthem has made headlines by starting a six-month waiting period to cover new medications and by refusing to pay for surgery for a 17-year-old boy with an unusually large breast.

        In the Madden case, Anthem finally changed its stance after an independent review board run by Medicare, called the Center for Health Dispute Resolution, ruled that the procedure should be covered.

        The surgery was performed July 20. Four days later , Mrs. Madden was walking a quarter-mile inside the hospital. She was back home seven days after the operation.

        “As far as I know, everything seems to be in order,” Mrs. Madden said.

        Although the treatment was a success, the family and the insurer remain divided over how well the system worked.

        “This illustrates that the appeals process did work for this patient,” said Anthem spokeswoman Diane Planck.

        But Mr. Madden remains incensed.

        “I wonder what would have happened if nobody went to bat for her? We waited two months for them to do the right thing,” he said.

        Mrs. Madden has a history of hypertension, coronary artery disease and a blockage in her carotid artery. She began seeking medical care about a year ago after she passed out in the beauty parlor.

Preferred procedure
        Tests failed to pin down a diagnosis, so Mrs. Madden went to Middletown Regional Hospital in March for an angiogram. Gary Brown, a cardiologist, found a 95 percent blockage in a coronary artery.

        He recommended bypass surgery but was concerned that Mrs. Madden might not survive an open heart procedure because of her frail health. So he referred her to Randall Wolf, a Cincinnati surgeon who specializes in “minimally invasive” bypass surgery.

        Rather than cracking the chest, minimally invasive bypasses are done by making small holes, called ports, between the ribs. Using a tiny camera and a special set of long, thin instruments, the surgeon does the bypass while viewing the work on a video screen.

        Dr. Wolf, who recently traveled to Europe to test a robotic surgery system made for these procedures, agreed to do the work. He wouldn't be using the robot system, just regular surgical tools, but Anthem denied coverage, claiming the procedure was experimental.

        Anthem was wrong.

        A Medicare regulation published in August 1998 “provides that cardiothoracic surgery using limited-access techniques is a covered Medicare service,” states a June 1 letter from the Center for Health Dispute Resolution.

        Anthem also claimed that Dr. Wolf was not part of Mrs. Madden's doctor network, and thus would not be allowed to do the surgery even if it were covered.

        Anthem sells its Senior Advantage Medicare HMO throughout Greater Cincinnati, but Medicare HMOs actually are licensed on a county-to-county basis. That means even though the plans might be offered by the same insurer, the prices, benefits and the networks of hospitals and doctors can change, depending on the county in which the patient lives.

        Dr. Wolf is on the specialist list for Anthem's Cincinnati plan, , but not for its Dayton plan. Mrs. Madden had the bad luck of living on the wrong side of the county line.

        Anthem didn't have a doctor in its Dayton plan that does the minimally invasive procedure. That's why Dr. Brown referred Mrs. Madden to Dr. Wolf in the first place.

        Mr. Madden appealed again, and called the media. On June 30, Anthem finally agreed to pay Dr. Wolf to do the surgery. She e needed another operation first to clear her blocked carotid artery.

        “Given the special circumstances, the proper appeals process was followed. The timing might not have been ideal, but everybody worked expediently,” Ms. Planck said.

        “You know what the ironic thing is? When it's all said and done, this will be a less expensive procedure because there's so much less recovery time,” Mr. Madden said.

        In this case, Mrs. Madden got the surgery she needed. But what if she died while waiting for the appeals to be resolved? Should the Madden family have the right to sue Anthem?

        “If she died in between, everybody would have been saying "it's not my fault,'” Mr. Madden said. “All this does is make you wonder how many of these stories are out there.”

        The right to sue HMOs for malpractice has been the most intensely debated part of patient bill-of-rights legislation in Ohio and before Congress. In both cases, after heavy lobbying from insurance and business groups, proposed rights to sue HMOs for punitive damages were removed before bills were passed.

        While Ohio's bill has been signed into law by Gov. Bob Taft, the federal version faces a veto from President Clinton.


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