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David R. Jones, Esq.

David R. Jones, Esq.

Posted: August 6, 2010 01:14 PM

Protecting Health Care Consumers

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As you may have read in the press, the Community Service Society (CSS) and its 25 nonprofit partners are in the midst of a struggle to keep one of the nation's largest and most successful health care ombuds programs alive in New York City ("Council Cuts Health Plan That Helped Poor People," New York Times, July 8, 2010). Rather than go into the details of that effort, I'm more focused on why this kind of consumer service has become a necessity in light of Health Care Reform.

Over the last 12 years, CSS and its partners have seen just how difficult it is for a lone individual or family to cope with the health care system. This is true for everyone. Start a conversation with virtually anyone at work or among friends and the stories start spilling out about trying to get a procedure covered at a hospital, a MRI approved, or a prescription filled that isn't on the approved list of the HMO despite being prescribed by one's doctor. And once there is a denial, the incredibly complex and time consuming appeals process makes even the most educated and persistent people throw up their hands.

But for many of the over 150,000 clients served by CSS's Community Health Advocates (CHA), formerly known as MCCAP, the obstacles become, effectively, insurmountable barriers. If you have limited education, cannot speak English well or at all, or if you have religious and cultural barriers which prevent you from using certain doctors and facilities, try navigating the HMO appeals process without a skilled advocate.

Moreover, while most insurance companies attempt to provide decent service, there is a tendency to put workers with the least training and discretion on the front lines of client service, where anything which is out of the ordinary is often met with a denial and instructions to appeal. There is also some anecdotal evidence that insurers, like other for-profits, are making it more and more difficult to talk to live people on the phone, putting people with questions or complaints through long waits, navigating through telephone trees in order to get the information they need and discover what is covered under their plan.

One story I tell over and over is of a mid-level HMO manager telling me that after a bad revenue quarter, they added 30-45 seconds to the on-hold wait on the telephone for people calling about denials. It led to an almost immediate bottom line improvement as people with relatively small claims simply gave up in disgust. We've all had similar experiences with utility and credit card companies. But the stakes go way up when dealing with health care.

How vital the stakes can be is illustrated by a recent case handled by CHA involving a woman named Carmen who "had a blood clot in my leg and I was told by the doctors that the clot could travel to my heart or brain at any time. I could die at any time. I did not have insurance; I was home bound and unable to navigate the system. I had applied for Medicaid through an HMO and they did not process my application. It was only after I contacted CHA (MCCAP) that my application was processed correctly. That is when I was finally able to get the blood clot treated."

When the Health Care Reform bill passed in Congress, the stakes for many Americans in negotiating with private insurance companies, hospitals, and doctors went up exponentially. Over 30 million more Americans will be covered in 2014. Many of these individuals -- because of the nature of their disabilities, income, and education -- are going to have a tough time getting what they're entitled to from health care providers.

It's for that reason that the Congress as a part of Health Care Reform provided for a modest funding of health care ombuds programs -- modeled in part on CSS's Community Health Advocates -- based on Senators Gillibrand and Schumer's intervention (Section 1002 of the Affordable Health Care for America Act: Health Insurance Consumer Information). If we have to take steps to level the playing field between big insurance companies and big hospitals and the individual consumer, health care ombudsprograms are a step in that direction.