Emory Report

March 27, 2000

 Volume 52, No. 26

Emory hosts Senate health policy forum

By Michael Terrazas

U.S. Sens. Max Cleland (D-Ga.) and Jack Reed (D-R.I.), both members of the Democratic Policy Committee, visited Emory March 20 to hold a hearing to discuss legislation aimed at reforming the nation's managed health care system.

In its last session, Congress passed conflicting versions of bills designed to strengthen patient protections for people enrolled in health maintenance organizations (HMOs). The House version was much stronger, potentially affecting all of the more than 160 million Americans currently enrolled in HMOs; the Senate version provided limited protection for 40 million people. A conference committee will meet soon to reconcile the two pieces of legislation.

Cleland and Reed, before a small audience gathered in the Emory Conference Center, listened to testimony from two mothers who went through difficult, even tragic experiences with their HMOs. Also testifying were Atlanta pediatrician Walker Ray, Medical Association of Georgia Executive Director Paul Shanor and Emory's own Art Kellermann, chief of emergency medicine at Grady Hospital.

Atlanta residents Lamona Adams-Hicks and LaTonja Threets-Hamp both testified about the difficulties they had in dealing with their HMOs. Threets-Hamp fell ill when she was six months pregnant. Her doctors recommended hospitalization, but Aetna U.S. Healthcare (which administers the University's HMO, EmoryChoice) denied the request and instructed doctors to send her home. When Threets-Hamp again began vomiting and running a 104-degree temperature, the hospital ignored the insurance company's orders and admitted her at its own expense.

Adams-Hicks told a story about her now-7-year-old son, James, who suddenly developed meningitis in 1993. When she found her son burning with a 105-degree temperature in the middle of the night, Adams-Hicks called her HMO, which instructed her to take him to an affiliated hospital 42 miles away instead of an emergency room nearby. She did, but en route her son lost consciousness and suffered full cardiac and respiratory arrest. James suffered irreversible damage to his extremities, and doctors amputated the boy's hands and feet.

Reed called the HMO system, which often puts health care decisions in the hands of actuaries instead of doctors, "cynical." "This is a system that hopes people give up, that makes it such a hassle to get health care that people just give up­­so [the insurance company] doesn't have to pay," he said.

Kellermann told his own personal story about his son, who several years ago complained of a sudden and agonizing headache. Well acquainted with the dangers of such a symptom, Kellermann told his wife over the phone to take their son to the emergency room, but the family's HMO later refused payment on the grounds that Kellermann had not first gotten a phone referral for the ER visit.

"Now some may quibble over what constitutes a 'prudent layperson who possesses an average knowledge of health and medicine,'" Kellermann said, referring to the people who staff an HMO emergency referral line, "but if the definition doesn't include a tenured medical school professor who is board certified in two specialties, we are in a heap of trouble."

Cleland and Reed repeatedly praised the House bill, authored by Georgia Rep. Charlie Norwood (R-10th), which is actually based on Georgia law. Shanor, whose organization filed a class action suit against Aetna last month for failure to pay claims in a timely manner, said Georgia passed "the most comprehensive 'Patient Bill of Rights' in the United States" in 1996, but the law only applies to about a third of the state's citizens­­the rest are enrolled in plans not accountable to state law.

"I hope the bill that reaches the president's desk echoes the protections guaranteed in [the House bill]," said Cleland, referring to such measures as an independent external appeal process and the ability to hold plans accountable in court for their decisions. "We must remove the overhanging dollar signs and financial disincentives that are stifling care and harming the public, and we must provide these protections to every person covered through managed care."

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