HMO Horror Story : Why Are Consumers Skeptical? Ask Jan Gribbon

When Jan Gribbon was asked to choose between several health care plans two years ago, she went with the most cost-effective option--a health maintenance organization that promised to keep her healthy and treat her when she was sick.

Gribbon is no longer a member of the HMO. Now she avoids them like the plague.

“Short of having no health care coverage at all, nothing would get me back into an HMO,� said the Los Angeles public affairs specialist. “I know that’s extreme. I’m sure there are probably good ones. But I am not willing to risk my health again to find them.�

Gribbon’s experience underscores the tough choice facing many Americans these days--to join an HMO or pay the often far higher costs that come with medical plans offering complete freedom to choose doctors. Gribbon was among the growing number of individuals who have joined HMOs as more and more companies turn to “managed-care� plans to control spiraling health care costs.

The advantage of HMO’s is that members may use the services as often as needed for a nominal fee per doctor’s visit or hospital stay. But members are also limited to certain doctors and hospitals.

Although most employers do not demand that workers choose managed-care options, they encourage the choice by making it more expensive to choose traditional indemnity insurance plans where insurers charge a premium for a period of coverage and usually pay 80% of a patient’s health care costs.

Companies ranging from General Motors to Atlantic Richfield Co. to Times Mirror Co. have recently revamped their health care plans, making indemnity plans largely unaffordable, workers say.

Employers want their workers to choose HMOs because they are far cheaper to provide, costing an average of $3,046 per employee versus about $3,573 for an indemnity plan, according to a recent survey by Foster Higgins & Co. in Princeton, N.J.

At the same time, employers argue that HMOs have vastly improved. Where these organizations once forced participants to visit a single facility to get health care, many are now made up of numerous health facilities and doctors. Most allow you to choose a personal physician, rather than getting care from whomever is available. And most have a broad range of specialists who can treat virtually any ailment at a fraction of the normal cost.

HMOs can save a fortune for families with children who have frequent checkups and for people with serious ailments, because visits to doctors and hospital stays generally cost the consumer only a few dollars. Such low out-of-pocket expenses, HMO supporters say, also encourage members to take advantage of preventive health care services, which reduces their overall expenses and is better for their physical health.

Still, many consumers are skeptical of HMOs. And horror stories such as Gribbon’s are the main reason why.

Gribbon ruptured a disk in her back while on business in Orange County. The pain was so great that she was unable to walk or drive.

With traditional insurance, Gribbon probably would have gone directly to a back specialist. But because she was in the HMO, she needed to go to her primary care doctor, who then referred her to a specialist. In great pain, she waited nearly two weeks for the referral to go through. In the meantime, she was told to take painkillers and muscle relaxants. The drugs made her drowsy, but the pain was still intense.

The specialist ordered a test, which took a week to schedule. When the results came back, the doctor said he needed another test because the first one wasn’t the best indicator of a ruptured disk. Why was it done? Because the HMO didn’t have in-house access to the test Gribbon needed. And the doctor said he didn’t want to go outside the HMO system. After another ineffective “in-house� test and nearly a month of waiting, the outside test was scheduled. It confirmed that Gribbon needed surgery.

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The HMO said the first available surgery date was in November--six months after Gribbon’s injury. And four months after diagnosis.

“I went ballistic,� Gribbon said. She had been out of work, on her back and in pain for nearly two months. She made dozens of phone calls. She complained. She threatened. Finally, the surgery was scheduled and, Gribbon’s new doctor says, botched. Now she needs monthly “nerve blocks� to quell the pain, and her neurologist says she’ll need another operation within a few years.

Most industry experts maintain that Gribbon’s case is highly unusual and shouldn’t cause consumers to avoid HMOs.

However, such horror stories should spur consumers to carefully investigate an HMO before signing up, said Jeffrey S. Harris, principal with Alexander & Alexander Consulting Group in San Francisco. HMOs have common features, such as assigning a primary care physician who controls members’ access to all services. But some HMOs are easier to negotiate than others.

Some of this checking can be done through your employer, which should be able to tell you why it chose particular HMOs: Did it investigate quality? The breadth of the HMO’s board of physicians? Variety of services provided? Accessibility of care? The ease or difficulty of negotiating the HMO’s administrative maze?

How satisfied are current HMO customers? Are there other company employees already covered by the HMO who will talk to you?

What your company can’t answer should be spelled out by the HMO’s member service department.

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Ask them how long a new patient may have to wait to see a doctor. Some HMO patients complain that first visits are often postponed for months. And HMO officials acknowledge that there can be quite a queue for these visits, particularly in January after many companies complete their open enrollment periods and the HMO has numerous new customers.

How long do referrals take? Is there a procedure to speed referrals in special cases? What sorts of tests and procedures must be done outside the system? And are you required to have numerous in-system tests before an outside test will be approved? Is there a procedure allowing compensation for outside care when the wait for HMO care is unreasonably long? What can you do if you’re dissatisfied with the care?

Does every member of the family need to see the same doctor or can each person choose a different primary care physician?

What provisions are there for emergencies when you’re far from the HMO hospitals? And what ailments are classified as emergencies? Would a child’s high fever qualify? A perceived heart attack? An epileptic seizure?

Those who investigate thoroughly may be able to save money and still get excellent care.

How HMOs Compare

Health maintenance organizations covered nearly one-fourth of all workers in health plans in 1991. HMOs generally cost less than other types of plans.

Percentage of workers covered Employers’ Annual by various types of health plans per-worker cost Indeminity plans 55% $3,573 Health maintenance organizations 23% $3,046 Preferred provider organizations 17% $3,355 Point of service plans 5% $3,291

Source: Foster Higgins & Co.