TOPICS > Health

Regulating Health Care in Arizona

April 11, 1996 at 12:00 AM EDT


UNIDENTIFIED HEALTH CARE WORKER SPEAKING TO DOCTOR: Headache, dizziness, high blood pressure, back and neck pain, CIGNA patient.

LEE HOCHBERG: Sunday night was a typical night at the Maryvale Samaritan Emergency Room in Phoenix. Patients streamed in steadily, but some had long waits, and it wasn’t because the emergency room was overcrowded.

HEALTH CARE WORKER: Patient signed in at 9:55. It’s 20 after 10:00. We’re still waiting for permission.

LEE HOCHBERG: That patient was one of several who waited an hour or more just to get authorization from their health maintenance organizations to be seen in the ER. HMO’s say it can take that long for their doctors to determine ER treatment is needed. Emergency rooms are expensive. One way HMO’s cut costs is to authorize visits. Patients with traditional insurance don’t have to await such authorization.

HEALTH CARE WORKER: Sholanda Warner.

HEALTH CARE WORKER ON PHONE: I’m trying to get an authorization for treatment on a Sholanda Warner.

LEE HOCHBERG: 85 percent of Maryvale’s emergency patients belong to managed care plans. To control costs, those plans decide on a case-by-case basis whether they’ll pay for ER care or tell their members to get less costly care in a doctor’s office. ER treatment often is delayed while HMO gatekeepers consider the case. Sholanda Warner came in with a deep gash over her right eye and waited more than an hour with her father.

UNIDENTIFIED WOMAN: It’s been an hour since the last time I spoke to them. We’re still waiting for an authorization.

LEE HOCHBERG: The delays in treatment are confounding emergency room physicians like Dr. Patrick Connell.

DR. PATRICK CONNELL, Emergency Room Doctor: The authorization process and the bureaucracy and the waiting on phone lines to get authorization for long periods of time often results in tremendous delays in getting patients expeditious care.

LEE HOCHBERG: In the State of Arizona, 40 percent of residents are in managed care systems. That’s slowed increases in health care spending, but along with lower costs have come some problems. Todd Girimillo and Aretha Victoria ran into problems recently when Victoria got the flu two months into her pregnancy. Her fever rose to 103.6, and when she began coughing up blood, she called Girimillo home from work to help her.

TODD GIRIMILLO: She looked absolutely terrible when I got there. She was burning up, and I knew that I needed to get her to an emergency room.

LEE HOCHBERG: At the Maryvale Emergency Room, Dr. Connell prepared to treat her for dehydration, but after 15 minutes, he got the word that the couple’s HMO didn’t consider Victoria’s problem an emergency. Payment for emergency treatment would be unlikely; Victoria should go home and see her HMO primary care doctor in the morning.

TODD GIRIMILLO: I blew up! I was like what, what did they say? You know, I got upset. I was, I was–my initial feeling was panic, was, like I can’t afford this man, no, no, what do I need to do to get this rectified?

DR. PATRICK CONNELL: Had we simply sent her out the door like the managed care plan wanted us to do, she could have jeopardized her pregnancy, she could have lost the pregnancy.

LEE HOCHBERG: Dr. Connell treated her. The bill came to more than $500. The HMO, Intergroup, one of Arizona’s largest, refused payment. Intergroup’s associate medical director, Dr. Naim Munir, says though the emergency room medical write-up clearly stated Victoria was coughing up blood, nobody had told the HMO gatekeeper, who decided not to authorize care.

DR. NAIM MUNIR, Associate Medical Director, Intergroup: Someone says you’re coughing up blood. Is that an emergency, yes, there’s no question that that’s an emergency.

LEE HOCHBERG: Then why wasn’t this immediately covered?

DR. NAIM MUNIR: Because, again, I go back to the same issue of I don’t know what was communicated. If someone tells me that there is a 22-year-old patient coughing up blood, yeah, it sounds like an emergency. It sounds like as a caring, compassionate physician, you should care about that. I don’t know what was communicated.

LEE HOCHBERG: After inquiries from the NewsHour, Intergroup paid the bill this week, but Dr. Munir says rejecting it at the time was prudent, and he says Dr. Connell should have called the HMO himself.

DR. NAIM MUNIR: I know it’s difficult, and everyone’s busy, but sometimes–if he had picked up the phone and talked to the physician on call and said, look, this is clearly an emergency, the patient’s worried that the bill is not going to be paid by the insurance company, is there any disagreement in your part, the whole situation, including the patient’s level of comfort with proceeding with further care could have been addressed right there and then.

DR. PATRICK CONNELL: You know, my training is to take care of sick people, and I’m, I’m often stuck as sort of the arbiter between the patient and their managed health care plan, and I don’t think that’s fair for me. I don’t think that’s fair for the patient.

LEE HOCHBERG: The Arizona legislature has passed a bill to try to avoid such confusion. Under terms of the Access to Emergency Health Care bill, HMO’s must cover screening and initial stabilizing treatment for patients. That bill awaits the government’s signature to become law. Another law awaiting the governor’s approval would have helped Phoenix area resident Charles Riggs. Riggs says he’s had to steer clear of his two active grandchildren as he’s waited six months to have a bilateral hernia repaired. His HMO, CIGNA Health Care, offered to pay for traditional open surgery, which require six weeks of recovery. He asked for a less invasive but more expensive laparoscopic procedure.

CHARLES RIGGS: The open surgery is obviously not in the best interest of the patient. Not only that, it’s barbaric. Why would you require somebody to have their abdomen cut open to do a procedure that is not necessary just because it’s the cheapest way to do it?

LEE HOCHBERG: CIGNA rejected his request, arguing there was no medical necessary for the procedure. Riggs filed a grievance with the HMO, but it was rejected too.

CHARLES RIGGS: They wrote me back and said that their decision was final and that there was no review to that decision.

LEE HOCHBERG: Riggs persisted nonetheless, asking an independent surgeon to argue his case to the HMO, but CIGNA still would not approve the procedure. Late last month, after a five- month battle, CIGNA reversed its decision and authorized the laparoscopic surgery. The company spokesman was unavailable to be interviewed, but in a statement, CIGNA said it had changed its mind based on an opinion obtained from an independent surgeon. Riggs will get the procedure next week.

CHARLES RIGGS: The whole issue here, though, is, again, not the fact that they denied my procedure, my request, but that there was no appeal to that denial. You had to accept their edict or go out and get a lawyer.

LEE HOCHBERG: Cases like Riggs inspired the Arizona state legislature to pass a bill, giving the insurance commissioner the power to oversee health care and managed care organizations. The bill was heavily opposed by most HMO groups, and it is not yet known whether the governor will veto it.