Sharlyn Cipriano (above) and Karen Rudy (r) hope to hit Capitol Hill with hundreds of stories from Northwest residents frustrated by their inability to get needed medical care.Sharlyn Cipriano and Karen Rudy are collecting horror stories for next week. But these two Gresham mothers have no interest in spooking trick-or-treaters with fables of ghosts or goblins. Rather, they hope to startle members of Congress with their tales of terror from the health insurance industry.
For the past nine months, Cipriano and Rudy have researched more than 30 cases in which Northwest health maintenance organizations allegedly withheld or delayed medical treatment. In the process, they've stumbled across a federal loophole that makes many health insurance plans virtually immune to medical malpractice lawsuits. Their work has caught the attention of U.S. Rep. Charlie Norwood, a Georgia Republican, and Sen. Alfonse D'Amato, a New York Republican, who are sponsoring a managed care reform package called the Patient Access to Responsible Care Act. PARCA would require HMOs to disclose rules such as capitation to consumers and would close the loophole that hinders civil suits against health care providers. Norwood's office has asked the women to come to Washington, D.C., to testify in hearings that could start as early as this week. Cipriano and Rudy are happy to to comply. Driven by their own HMO horror stories, they hope to arm legislators with real cases and bring the problems with managed care into the public eye. "We want the HMOs to be accountable for their actions," says Cipriano. Cipriano and Rudy met about a year ago, purely by chance. Cipriano, a dental assistant, was battling PacifiCare; her primary doctor had delayed ordering an expensive MRI test that would have helped diagnose her herniated disc. She was making photocopies for her appeals process in a store that Rudy ran. Rudy was fighting with her own HMO at the time. They shared their health care stories and began their partnership. Together, the two began collecting stories by word of mouth, asking doctors and talking to other moms during soccer games. One of the women they met is Julie Markham, a Fred Meyer dispatcher who is battling breast cancer ("What's on Your List Today?" WW, Oct. 15, 1997). They have taken their collected stories to lawyers, legislators and the state Insurance Board. "We need a voice and a place to come together and share our information," says Cipriano. Complaints about health care have been around as long as there have been doctors. In recent years, however, there's been a twist. In the past, patients often accused doctors of prescribing unnecessary treatment, but consumers in managed care plans increasingly complain about being denied health care. That's because the old "fee-for-service" system, where insurers paid doctors for every treatment given, has been replaced by a "capitated" system, where insurers pay doctors a flat monthly fee per patient, regardless of whether the patient's care costs $5 or $50,000, giving providers a financial incentive to withhold care. In most of the cases collected by Cipriano and Rudy, HMOs allegedly denied or delayed expensive medical treatment that would have resolved the patients' problems. But the local effects of capitation are only part of the problem that Cipriano and Rudy see with managed care insurance plans. They've recently shifted their focus to the federal level and the Employee Retirement Income Security Act. Created by Congress in 1974, ERISA, as it's known, regulates certain employer-provided benefits such as health and pension plans. Prior to this legislation, employees had no legal recourse when companies failed to pay their benefits. ERISA, however, also had unintended consequences for people who are insured by an employer health plan. The rules determining which plans fall under ERISA are complex, but an aide to Norwood says it affects up to 70 percent of managed care plans. Under ERISA, when such a patient sues his or her HMO or doctor for malpractice, the lawsuit is thrown into federal court, where trials are often less appealing to personal-injury lawyers. "Fighting a battle in federal court is a much lengthier and expensive process," says Larry Wobbrock, a medical malpractice lawyer in Portland. Even worse, the law says that patients who sue can only claim the value of the medical services they were denied, not damages for pain and suffering--which is where the big money comes in for the patient, and the lawyer. ERISA has, in effect, made many HMOs off-limits to consumer lawsuits. Rudy's case is a good example. Rudy was born with a cleft lip and palate, requiring extensive reconstructive surgery and dental work. A former Federal Express driver, she has health coverage through the company, where her husband still works. Yet when Rudy's reconstructive dental work recently deteriorated, and recurring infections in her mouth mandated that she have more reconstructive work done, Cigna, her HMO at the time, denied the request, saying her reconstructive medical and dental surgeries were not a covered benefit. She contested Cigna's response, noting that Oregon state law specifically requires medical insurance plans to cover the special needs of cleft lip and palate patients. But because her health insurance is covered under ERISA, Rudy was told that Cigna answered to federal, not state, laws. When Rudy decided to sue her HMO for not adhering to state laws, she again was stymied. Again, ERISA was cited. "I sent every lawyer in town my story, and every single one of them said that because this is an employer-provided plan governed under the ERISA Act, that the HMO is going to be untouchable," says Rudy. One lawyer estimated that a federal trial would cost about $80,000, Rudy says. And because ERISA limits the HMO responsibility to medical costs, Rudy could hope to win only $20,000. "He told me it would cost less to just pay for the surgeries myself," Rudy says. Rudy sold her car to pay for the $4,000 worth of maintenance work she's had over the past two years and is considering selling her house to pay for the surgeries she still needs. For Rudy, who is limited to a soft-foods diet, the surgery is far more than cosmetic. She says that if she doesn't get her reconstructive surgery and dental work soon, she won't be able to talk. That, in part, is why she and Cipriano are so eager to get to Washington. The Norwood /D'Amato Patient Access to Responsible Care Act would get rid of the ERISA preemption clause, which would allow managed care patients to sue in state courts and, in some cases, seek damages beyond the actual cost of the denied procedures. "We want to go to Congress and participate in hearings," says Cipriano. "We've decided that we can't just stay in Oregon. We have to go to the federal level." "We get so frustrated while researching these stories, but we keep pushing one another to continue," says Rudy. "We're determined. I don't want this happen to anyone else." |
