EFFECTS OF MANAGED CARE

Most HMO Doctors Upset at Denial of Care
They fear affect on patients' health, survey says

Tom Abate
 

   --  Health plan denials reported by physician. --

    The nation's physicians overwhelmingly view managed health care plans as having a negative effect on the care they are able to give their patients, according to a survey by the Kaiser Family Foundation.
    Almost 9 of 10 doctors said that over the last two years their patients have been denied coverage for health services by a health plan.


Nine out of 10 doctors in a nationwide survey said they have patients who have been denied care by health insurers, a problem so frequent and frustrating that half of all doctors surveyed admitted they often exaggerate the severity of illnesses just to get an insurer's approval.

The frequency of coverage denials, and the effect these denials have on the health of patients, are key findings in a report issued yesterday by the Henry J. Kaiser Family Foundation. The foundation is a nonprofit health care research group in Menlo Park and is independent from the Kaiser Permanente HMO.

The study found that denials of coverage for mental health services have the most profound effect on patients' health, with nearly two- thirds of doctors surveyed saying that a treatment denial in the mental health area caused a ``somewhat serious'' or ``very serious'' consequence -- up to and including suicide.

``This is the first time anyone has tried to quantify the consequences for patients of denial of care,'' said Larry Levitt, a Kaiser Foundation analyst who analyzed the findings.

The study is based on a national survey of 1,821 doctors and nurses, chosen at random. The survey was designed by the Kaiser Foundation and the Harvard School of Public Health and administered by the National Opinion Research Center.

Insurance industry representatives questioned the findings and timing of the report, which was unveiled as Congress and the California Legislature are considering several bills to regulate HMOs.

Karen Ignagni, president of the American Association of Health Plans, the HMO trade association, said the study is skewed; because doctors see so many patients each month, she said, they're bound to experience coverage denials. Ignagni cited a different, 1998 survey of American voters which found that 82 percent said no one in their family had experienced a denial of coverage.

``The (Kaiser) report does not provide the information that would be needed to draw broad conclusions about the frequency or appropriateness of coverage decisions,'' said Ignagni, who cautioned against using it to advance ``a political agenda.''

Her warning came as leaders in the U.S. House of Representatives maneuvered to bring an HMO ``patient's bill of rights'' directly to the House floor, bypassing committees that have failed to produce legislation.

The Kaiser report is not completely negative on HMO-style medicine, often called ``managed care.'' Nearly half of all the health professionals surveyed said managed care increases the likelihood that patients will get preventive medical services, like flu shots.

But for the most part, the report documents the resentments of doctors and nurses having HMOs second-guessing their coverage decisions.

Disagreements over prescription drugs are the most common complaint, with 61 percent of doctors saying that, at least once a month, they have to argue with an HMO over a prescription. Levitt, the Kaiser analyst, said most of these fights occur when a physician recommends a name-brand drug and the HMO wants to pay for a generic variety. Such differences are usually resolved without any real effect on patient care, he said.

But the stakes can be higher when the doctor and the HMO disagree over authorizing a diagnostic procedure, like an MRI scan, or referring a patient to a specialist. Forty-two percent of doctors said they argue with HMOs over diagnostics at least once a month. And 29 percent said tussles over specialist referrals also occur at least monthly.

When such denials occur, nearly half the doctors in the survey said they consider the health consequences to the patient to be at least ``somewhat serious.''

The report tried to drive home the statistics by including comments where doctors describe specific denials. ``A patient with long- standing migraine headache experienced a change in the nature and duration of headache,'' one doctor wrote clinically. ``MRI denied; patient had a subarachnoid hemorrhage a few months later.'' Walter Zelman, president of the California Association of Health Plans, the lobbying group for the state's HMOs, said doctors in California have far more leeway than doctors elsewhere to make referrals or to order diagnostic tests without HMO interference.

Zelman said that in California, virtually every doctor belongs to a medical group that acts as the intermediary between patients and HMOs. For every insured patient they treat, the medical group gets a fixed fee from the HMO - which leaves it up to the doctors' group to decide whether to authorize specialist visits or diagnostic tests.``In California, more than in any other state, there aren't insurers looking over the physician's shoulder,'' Zelman said.

Levitt agreed that California doctors have more freedom to approve some procedures. But for prescriptions, hospital stays and mental health treatment, insurers still set the coverage rules in California, he said.

Because of insurers rules, two- thirds of the doctors surveyed nationwide said they routinely have to play patient advocate to get an insurers' OK for a specific procedure. About 42 percent of the time, the doctors got their way, the survey said. HMOs won about 22 percent of the arguments, with the rest being compromises or continuing debates.

``This level of conflict and administrative haggling between doctors and plans can't be good for our health care system or for patients who are often caught in the middle,'' said Kaiser Foundation president Drew Altman. The report's key findings are posted on the foundation's Web site at
www.kff.org.

BC:
.
    -- During the past two years, how frequently did an insurance plan
not  approve...
                                     
                                 Weekly/    six months/                Not applicable
                                  monthly      yearly       Never       to my practice
A prescription drug       61%         18%          9%              8%
A diagnostic test/
procedure                     42%         27%           16%            8%
A hospital stay              31%         29%           19%           16%
A specialist referral       29%         23%           25%          16%
A referral for
mental health                 18%         20%            28%          26%


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