Managed care: A patient's perspective

Colburn-Moraites is among a growing group of frustrated HMO members  IN-DEPTH SPECIAL: The HMO debate  MESSAGE BOARD: Debating HMOs

June 27, 1999
Web posted at: 12:28 p.m. EDT (1628 GMT)

In this story: Complaints spur proposed legislation RELATED STORIES, SITES

WASHINGTON (CNN) -- It took Elizabeth Colburn-Moraites some time to get the medicine she needed to clear her eyes -- but she is still in the dark about some decisions made by her health maintenance organization.

Colburn-Moraites recently sought a doctor's treatment for blurry vision caused by multiple sclerosis. She had joined an HMO because her neurologist was enrolling with the plan, but as a new managed-care patient, she was told to see a primary-care doctor for a referral.

And though Colburn-Moraites couldn't walk without help and her vision was cloudy, she was forced to wait more than a week for an appointment: Her condition was not an emergency, the HMO said.

"If I can go into a hospital and get stitches today, why can't I go in and get treated for not being able to walk well or for having visual problems?" she asked.

The situation left Colburn-Moraites frustrated -- and, like more than 70 percent of HMO enrollees, wishing she could have more say in managed care decisions.

Even after Colburn-Moraites received the steroid treatment she needed, her insurance company refused to pay.

"It took me three months to find out that they were finally going to pay for this, and I was really given no direction (on) who to write or how long it was going to take," she said.

Democratic lawmakers say 115 million Americans report that they or someone they know have experienced similar problems.

Those complaints are why the American Medical Association is backing both the unionization of doctors and a patients' bill of rights, which would mandate access to specialists and an independent grievance process.

"Most of the power (lies) in the hands of the insurance companies ... leaving patients often times with a premium paid and care not available," said AMA President Nancy Dickey. "We've got to level the playing field."

But Republican lawmakers and managed-care representatives say the proposals will drive up costs and make health care more expensive for consumers.

Given more leverage over health insurers, a national labor union for doctors could push premiums up by more than 10 percent, warned Chip Kahn, president of the Health Insurance Association of America.

And a patients' bill of rights -- which could include mandated hospital stays for certain procedures and the right to see doctors outside the network -- also could end up hurting patients in the pocketbook, skeptics say.

"We are in danger of legislating out of existence the very techniques that health plans use to keep costs affordable," said Karen Ignani of the American Association of Health Plans.

Medical Correspondent Eileen O'Connor and The Associated Press contributed to this report.