TOPICS > Health

Regulating Health Care in Arizona

April 11, 1996 at 12:00 AM EDT


ELIZABETH FARNSWORTH: Joining me tonight are State Senator Ann Day, who was instrumental in sponsoring those bills; Stuart Grabel, a consumer advocate with the PEMA Council on Aging; Marjorie Marks-Catz, a patient at a health maintenance organization; Dr. Naim Munir, who was just featured in our taped segment; Edna Wilson, who handles patient complaints for FHP Health Care; and Steve Barclay, counsel and lobbyist for the Arizona Association of HMO’s. Thank you all for being with us. You heard the case–cases in the taped piece. Is that somewhat typical? Is that an overstatement? Are these anecdotes that don’t prove anything? What do you think, Senator Day?

STATE SEN. ANN DAY, (R) Arizona: Well, clearly, I think in Arizona, where we have a significant portion of our population in managed care that as more people are in managed care, we will see more problems with the system, and I think the incentive is there in trying to keep costs down to reduce services at times. And the problems that mainly hear about are problems people have with referrals or problems with a prescription drug that they want, or getting appointments mainly.

ELIZABETH FARNSWORTH: What do you think, Steve Barclay? Do you think that looking at these anecdotes is misleading?

STEVE BARCLAY, HMO Advocate: I think it can be. I think you have to look at them. You can’t ignore them but you have to look at other measurement tools. You have to look at satisfaction surveys, for example, the one the Hospital Association did here with the Gallup Poll that said 86 percent of Arizonans in managed care are very satisfied with their plans, and that was a higher rating, by the way, than the indemnity or PPO, which is preferred provider organizations got in their sampling, so I think you have to look at beyond just the anecdotes.

ELIZABETH FARNSWORTH: And what do you think, Mr. Grabel? You’re hearing from elderly people. What do they say?

STEWART GRABEL, Patient Advocate: Well, I think we have to keep in mind what an anecdote is, and it’s a story of a real life person, and there are a significant amount of them. We get calls in our office every day with similar stories, with similar situations in which people have been denied services. And it’s very important that we pay attention to these because what’s happening in Arizona is being repeated across the country. If the future is HMO’s or managed care, then we have to correct the blemishes in order to make it work properly.

ELIZABETH FARNSWORTH: Now, Edna Wilson, you deal with these kinds of complaints. You deal with these calls within the HMO, within the organization you work for, so you do deal with the complaints and try to correct them, I assume, right?

EDNA WILSON, HMO Grievance Representative: Yes, I do. As a matter of fact, I don’t see as many now as I have in the past, I have to admit. HMO’s have been around for quite some time, and I have to admit that initially, yeah, there was some problems within the system, but I think we’re making strives in correcting them, and I see less and less of that now, and I do deal directly with these things. The population of an HMO, how big is our population now as compared to the types of complaints or the numbers that you’re hearing about?

ELIZABETH FARNSWORTH: Why? Why are there fewer complaints now–


ELIZABETH FARNSWORTH: In your experience.

EDNA WILSON: In my experience?

ELIZABETH FARNSWORTH: What’s changed in your company?

EDNA WILSON: We’ve–because we’ve listened to what the customer’s needs were. We have– we have what we call a customer service department, in our organization it’s called a member services department, and we listen to the complaints from the members, and we’re doing something about those complaints. As a matter of fact, we were talking about emergency room denials. I don’t see that many, and I deal with formal complaints from the members right now and claim denials, and we have new contracts in place to prevent those things from happening.

MARJORIE MARKS-CATZ, HMO Patient: Senator Day had mentioned two issues that she hears about, the issue of referrals and the issue of denial of prescription medications. And from a patient’s point of view–

ELIZABETH FARNSWORTH: And you–you’ve had cancer, right?

MARJORIE MARKS-CATZ: Right. I’m a cancer survivor, and those are the two issues that I found the most difficult to deal with. For example, the issue of prescription drugs, prescription medication, I’ve had three different physicians within the HMO prescribe a medication for me and it’s continually denied. And as a result, I have to pay $125 a month out of pocket for this medication. And it does not leave me with the feeling of security because if three different physicians who I respect and whose medical judgment I respect prescribe a very well-known medication and the HMO is denying it because they’re telling me it’s not in their formulary, then there’s something not quite right.

ELIZABETH FARNSWORTH: Okay. Dr. Munir, do you think that the problems are a few anecdotes here and there? How do you judge the nature and the scope of the problem?

DR. NAIM MUNIR, HMO Administrator: I try to look at the problem objectively. When you look at the member satisfaction surveys, I think members have been very pleased with the care that they’ve been receiving with HMO’s. I think it would be wrong to say that HMO’s are perfect. There are these blemishes that we talk about. There are these blemishes; however, I think HMO’s have brought physicians together, have brought hospitals together, and have allowed a forum for us to solve these problems. I think we’re getting excellent at it, and I think for the first time at least being trained as a family physician, I’ve had the opportunity to see the health care system fully work as a system. I think in the past in the 1960’s, it was an illness-based, non- system. I think HMO’s allow all the active participants in health care to sit down, measure quality, which I don’t think has ever really been measured before in the health care environment.

ELIZABETH FARNSWORTH: Okay, Senator Day, we may differ on how severe the problems are, but there have been problems, and that’s why you have pushed some legislation, right? What is your legislation aimed at correcting? Go through just a little bit of it briefly.

STATE SEN. ANN DAY: Well, this year I dealt with quality of care, and I think that quality of care is starting to compete with the reduced cost. And clearly, people love having the $5 co-pay or a $10 co-pay, but I think that as managed care has evolved, practically in our backyard, and now employers are buying HMO’s because it’s cost-effective, that people found themselves restricted, and they couldn’t make choices. And the problem is that when you’re in a managed care environment or an HMO, the managed care, the HMO is making all your decisions for you. And when they get a license to operate in the state, they promise to deliver quality health care. And the question begs itself, what happens, where do you go, when they don’t deliver quality care? And the answer is that you go to their grievance process, which is theirs, bought and paid for, and if you’re denied, you’re at the end of the road, and you have no place to go but to me, an elected official, or to file a lawsuit.

MARJORIE MARKS-CATZ: You mentioned the issue of control. And as a cancer survivor, one thing I learned as a cancer survivor is the importance of advocating for your own health care and the importance of listening to your body. And I had an incident, umm, last year when I had quite severe symptoms, went to my primary care physician and asked for a referral to a specialist because I felt, umm, that the symptoms that I had required the services of a specialist. Umm, he refused to give–he’s the gatekeeper. He’s now in control of my body and in control of my medical care. He refused to give me the referral, so what I went and did was, umm, changed primary care physicians. But from the time I had the symptoms until the time I finally changed the PCP, got the referral, made the appointment with the specialist, saw the specialist, had all the tests necessary, four months went by, and I was having severe pain.

ELIZABETH FARNSWORTH: Thinking generally, is legislation the way to go?

STEWART GRABEL: There has to be some kind of legislation. What we’re dealing with, and what we were talking about just a moment ago, was someone who is articulate and capable of explaining what was happening to her and following through on dealing with the procedure. Among our sick people, among our people who require health services, there are a lot of people who are totally incapable of doing that. To not have an entity that can assist them through that process is to really deny them health care, to really deny them the ability to deal with it. And a managed care system is essentially in some ways an adversarial system, i.e., the checks and balances are set on the, on the premise of saving money, and in order to receive services, you have to advocate for yourself, you have to say to your primary care physician, I need to get additional services. If you’re a senior citizen, if you’re 75 years old and you’ve been taught that the doctor’s word is law, you’re not going to do that.

ELIZABETH FARNSWORTH: Dr. Munir, is this, is this the future, where, where–the stage where legislation, various medical associations, and HMO’s will negotiate, work out, perhaps have legislation regulating the procedure, but basically this is the future, this is where medical care is going to be delivered?

DR. NAIM MUNIR: I believe so strongly that the future is going to be collaboration, but I don’t believe it’s going to be regulation. I think the focus of discussion back to the key issue, the majority of patients enrolled in HMO’s are satisfied with their carrier. These are satisfaction surveys that are done by independent folks. Now, when there are these types of issues where the system breaks down, being trained as a family physician, the communication between patient and physician I think is ultimately important and for that physician to be the patient’s advocate within the managed care system. If there is a patient who’s having difficulty and having denials that they perceive to be unreasonable, that physician, the reason I’m employed and part of the HMO, the reason I work within that system is to allow opportunity for physician-to-physician contact. In the piece that we saw earlier tonight, I think that was where there was a breakdown also. There was a lack of physician-to-physician contact, and I don’t think any amount of regulation is going to overcome those type of communication issues.


STATE SEN. ANN DAY: Elizabeth, I think the health care marketplace is different. We’re not talking about commodities. We’re talking about human lives. And I think for there to be fairness in the health care marketplace, there have to be checks and balances. We’re not dealing with widgets. Health plans are not selling widgets. They’re promising to deliver quality care, and I have to disagree that people are satisfied. I think there is a backlash against HMO’s nationwide.

ELIZABETH FARNSWORTH: There is a lot of legislation. Thirty-three states have legislation.

STATE SEN. ANN DAY: In some states, it’s a war. Now, do I think that you always need legislation? No. And, in fact, in Arizona, there are examples where outside of the legislation process there have been agreements on the maternity stay for newborns that was done without legislation. Then the Emergency Services Bill that was referred to earlier was negotiated and compromised in the legislature, and then we have the Quality of Care Bill that was never compromised because it’s “regulatory.” And here in Arizona, we don’t like to regulate, but as I said, we’re dealing with human lives, not commodities.

STEVE BARCLAY: I agree we’re not talking about widgets here. We’re talking about human lives. We’re talking about patients. But there’s an underlying premise here that I completely reject, and that is the premise that we don’t care about our customers, our patients, our members, that we don’t put their interests at heart, that all we care about is the process. We will not stay in business, it’s as simple as that, we will not stay in business if we don’t treat people well. We would not have grown from 700,000 members in HMO’s in 1988 to almost 1.5 million if we hadn’t been treating the vast majority of people well.

ELIZABETH FARNSWORTH: Now, explain how that works. That’s because an employer, if their employees are really miserable with their health plan, simply will go to a different health plan, is that, is that the way that–is that why? You are self-reforming, is that what you’re saying?

EDNA WILSON: They have the option to do that, right. We want to retain the membership, so obviously we want to keep them as satisfied as possible.

STEWART GRABEL: However, that equation works to a point. That equation works as long as it’s economical to market to those groups, to those people. None of the doctors here, none of the individuals here would ever think of denying a patient care that was appropriate for them; however, the system does. And that’s what we’re seeing, and that’s the effect. And what we’re seeing is the effect of that.

DR. NAIM MUNIR: I’d like to step back and talk about accountability because I think that’s what we’re talking about. Are you going to hold HMO’s accountable by anecdote? The anecdotes are important, and that’s why there are people like me at HMO’s who when there are issues that don’t make sense to physicians hopefully that communication occurs at a per human being to human being level. But I–I think to have a discussion and not talk about the National Committee for Quality Assurance would be a mistake. I think that organization is a non-profit organization established in 1978 with the consumer representatives, including a senior investigative reporter from Consumer Reports–

ELIZABETH FARNSWORTH: This is the organization that does go around that you are accountable–

DR. NAIM MUNIR: It’s a national organization, and hold HMO’s accountable for measurably demonstrating that the HMO’s have improved the quality of care and services rendered to their members. I think for us to somehow pretend that HMO’s don’t care about the members or don’t want to deliver the best possible quality care is just to simplify things.

STATE SEN. ANN DAY: That’s a trade organization. That’s the HMO’s trade organization. I call it a shell group. And that organization even states that they do not have the standards by which to measure outcomes, that by using their standards you can’t compare one HMO against another– with another. And I do think that’s where we need to head. We need to have standards for the different diseases, so that we can get good outcome measurement, so that we will have comparisons of one HMO against another.

ELIZABETH FARNSWORTH: And very, very briefly, the problem with that is–

STEVE BARCLAY: These are very complex and difficult subjects. The only way we’re going to be able to beat this, and we can’t turn back, we got to look ahead, the only way we can beat this thing is if we work cooperatively together. And the example of the emergency room bill this year that we hammered out and the maternity length of stay issue which we got worked out without legislation are good examples. We’re going to continue to work with Sen. Day and the rest of the legislature to try and solve these problems. Amazing things happen when we sit down at the table and talk to one another and, you know, address these issues. We can resolve them, but we’ve got to do it in more creative ways than legislating and regulating because those drive costs, and I don’t think they drive quality.

ELIZABETH FARNSWORTH: Well, thank you all very much for being with us.