Americans See Problems, Promise of ‘Managed Care’ : Health: The concept is basic, but the devil is in the details. As plans vary, so does the quality of treatment.

When Joan Ravenna had a heart attack a few years ago, she had to wait more than 20 hours before being examined by a cardiologist. As she remembers it, she could easily have died that day as a result of flaws in the system of “managed care” that President Clinton is advocating for all Americans.

“Managed care is not good medicine,” said Ravenna, 44, of Evanston, Ill.

Georgia LeSire would disagree. At age 66, LeSire, of Fremont, Calif., has been a subscriber to the pioneering Kaiser Health Plan for nearly a half-century and has nothing but good things to say about that version of managed care.

“We’ve always said Kaiser offers the most, the best, for the least price,” LeSire declared. “If everyone had it, they would have the best care.”

All across the country, Americans are standing on the brink of what promises to be a hard-fought battle over the basic design of a new health care delivery system for the nation. And unlike Ravenna and LeSire, many of these Americans have no direct experience with the managed care concept that is expected to form the centerpiece of Clinton’s program.

The exact details of the President’s plan will not be announced until next month, but already it is clear from the experiences of those who participate in managed care programs that it is a concept rich in potential for both promise and problems--a strategy capable of delivering both the best and worst in health care.

The devil, experience suggests, is in the details.

The reason: The quality of managed care is inconsistent across the country, ranging from programs that get rave reviews from consumers and experts alike to others that are considered dismal failures. That helps explain why managed care is relatively popular among patients in some areas of the country--California, Massachusetts and Maryland, for example--but is not highly regarded everywhere.

“When you’ve seen one managed care program, you’ve seen one managed care program,” said Jacque J. Sokolov, a Santa Monica physician and consultant to managed care organizations. “No two . . . are identical.”

For Clinton’s health care reform plan to succeed, most Americans will have to accept some measure of rationing of care, and managed care is currently the most popular model. But the thing that experts most admire about managed care--its ability to save money--is not necessarily the mark of a good plan for all consumers.

Different Plans

Most of the 550 managed care plans in the United States share at least one characteristic: A patient selects a primary physician who belongs to a large group and who--working under the scrutiny of plan administrators--controls that patient’s access to specialists, hospitalization and diagnostic tests.

But there are different types of managed care plans, including health maintenance organizations, preferred provider organizations and exclusive provider organizations. Under the most restrictive plans, patients must be treated by doctors at a central clinic. Under the least restrictive, patients select from a list of doctors who have agreed in advance to accept the fees that the plan pays.

The most popular managed care plans, according to a survey of Consumer Reports readers, are those that offer a wide choice of doctors and specialists. Indeed, those plans chosen as the best in the survey were the closest to the old-fashioned, fee-for-services indemnity health insurance that reimbursed patients for consulting any doctor of their choice.

Complaints usually center on difficulty in obtaining emergency care, getting care while away from home, obtaining referrals to specialists and contending with complicated rules guiding coverage. Some plans also have been criticized for using cleverly written rules to avoid paying for the most expensive medical services, such as emergency care and mental health services.

But if a system operates under a philosophy that does not blindly put cost constraints ahead of patient welfare, has well thought-out rules and a competent staff with the knowledge and flexibility to apply them sensibly, the outcome can be positive for the patient.

The stories of six people across the nation offer examples of the kinds of failures and successes experienced by participants in managed care. Each offers a lesson in potential problems, as well as how they might be avoided.

Emergency Care

One major complaint about managed care programs centers on often-confusing rules for obtaining emergency service. Joan Ravenna, a divorced mother of two children who considers managed care a failure, offers her experience to explain her feelings.

“My son was in a school bus accident in 1988,” she recalled. “The paramedics took him to the nearest emergency room, but the HMO refused to pay for the treatment because it was not authorized. . . . I theoretically had comprehensive coverage. But it cost me $1,000 to $2,000 for his emergency treatment.”

A year later, she said, she suffered a heart attack. “I was afraid that if I went to the emergency room myself, they wouldn’t pay for it. So I drove home and called the HMO number.

“They told me I had to go to the hospital in their private ambulance. I waited 30 minutes for the ambulance to come and it took them another 30 minutes to decide which hospital to go to. They literally drove in circles with the siren on, talking on the radio, and I was in the middle of having a heart attack,” she said.

Ravenna said that she remained in the hospital overnight without treatment while awaiting the arrival of a doctor approved by her HMO. “When a cardiologist finally saw me, he quickly put me in intensive care. I heard him yelling at the staff, ‘Why isn’t this patient in ICU (intensive care unit)?’ While I was waiting for treatment, I could have died. . . .

“The people who are happy with these plans are people who have not needed them--people who are healthy. I have cards in my wallet that say we’re covered for everything, but I have experience that says we’re not.”

Managed care systems do not have to work that way, however, and not all do.

Out-of-Town Care

Billy Feathers, 52, of Blountville, Tenn., is living proof of that.

A chemical operator for Eastman Kodak, Feathers fell ill last summer with pancreatitis while vacationing in Florida.

“It was after a walk on the beach,” he said. “I went into my hotel room and suddenly fell to my knees with an excruciating pain in my stomach. . . . I put up with it for about 10 or 15 minutes and finally told my wife to get me to a hospital.”

Feathers said that he remained hospitalized in Florida for two weeks. “They just tried to get me well enough to go home,” he said. “They couldn’t operate--I was too bad off.”

Finally, he was well enough to make the trip. Once home, he was rehospitalized and underwent gall bladder surgery.

“All I can say is that it (managed care) is great. They paid for everything. . . . I got one bill for $147,000 and another for $50,000. That did not include the doctors. All it’s cost me so far is $36.50.”

Referrals to Specialists

Jane Flood, 56, a widow and recently retired teacher in Bronxville, N.Y., was seeing a psychotherapist three times a week when her company switched to managed care health coverage in February, 1992. Her old plan paid about $30 for every $90 session.

After the switch, Flood’s therapist joined the managed care network of specialists to continue treating her. The new plan promised to pay $75 each for “unlimited visits,” as long as they were certified by the plan as medically necessary.

“While I was waiting for the new plan to certify me for therapy, my husband died suddenly,” Flood said. “In addition to that, I was trying to cope with many other problems. I continued to see my therapist and I soon owed her $4,000.”

It was not until September, Flood said, that she received any word about certification. “During that time, I made repeated efforts to find out about the status of my care. The intrusion and violation of my privacy was painful and humiliating. I spoke with reviewers who did not have the same professional training as my therapist and who did not have answers for me.”

On Sept. 17, Flood said, her therapist received a call from a plan reviewer--a sort of supervisory therapist who works for the managed care company--who said that Flood’s sessions from February to September would not be covered and only four more visits would be authorized. The remaining visits, the reviewer said, would be contingent on a psychiatric consultation and the prescribing of medication.

“These decisions were made by telephone by someone who disagreed with the professional evaluation of my therapist. He didn’t know me. I didn’t want to take medication. I was scared of the side effects, but I did it anyway because I was afraid they wouldn’t pay for my treatment otherwise. I felt that the decision of this doctor intruded in my care.”

Flood said she was later told by another doctor to discontinue the medication for medical reasons.

Ultimately, Flood took her case to the state insurance commissioner and obtained reimbursement for her earlier expenses.

” I feel that the treatment I received . . . was terrible. I have paid a price emotionally and financially,” she said.

Chief among the benefits of managed care, participants say, is good preventive care.

Ann Coschigano of Wappingers Falls, N.Y., a 43-year-old hair stylist, is among the champions of such programs. Coschigano has two healthy children--the first born under the old-fashioned indemnity health insurance plan and the second born under managed care.

During both pregnancies, she was forced to stay in bed for weeks to prevent a miscarriage. Under her managed care plan, she benefited from a special program designed to assist risky pregnancies. This program, in addition to supporting the best care for the expectant mother, helps the insurer avoid the enormous costs that can result from the birth of premature babies.

“I was pregnant with my daughter, the youngest, Alissa, when we moved to managed care in 1991,” Coschigano said. “I went into pre-term labor at 26 weeks and needed to be home in bed for the rest of the pregnancy. I had to have total bed rest. But I had an 18-month baby at home.

“They (her managed care firm) were wonderful to me,” Coschigano said, explaining how she was hooked up to computers to monitor her health status. “I had to call the company three times a day” to transmit a tape that measured uterine contractions. “There was a woman who came regularly to check that I was O.K. and on the proper medication. In fact, the nurses would call me often to check on me.

“I also needed someone to watch my son, Daniel. They had someone come in for that, too. They paid for everything. I don’t know what I would have done if they hadn’t. I have no idea how much it cost, but my husband says we paid only $400 or $500 for the whole thing.

“I had the same trouble when I was pregnant with my first child. It had taken me 18 years to become pregnant and I wasn’t going to lose it. But that was before we switched to (managed care) and I had to do a lot of fighting to get the insurance company to pay the bills.”

Complex Rules

Linda Penno, 42, of Louisville, Ky., a law student and a physician who has worked as a consultant for several firms specializing in managed care, views the rules governing some managed care plans as “Kafkaesque.” From her firsthand experience, she knows how companies can use these rules to deny benefits.

“When I first began my work as a medical consultant,” Penno recalled, “an accountant with the insurance company explained the simple arithmetic of my job: ‘We take in a premium, we use about 10% to 15% to run the business, and we try to keep as much as possible of the rest. Your job is to help us do that.’ ”

Penno said she felt pressured to “find medical reasons to make economic decisions.”

In one company, she said, she was expected to deny at least 10% of requests for medical procedures and competed against other medical consultants for a Christmas bonus to be given to the employee with the highest denial rate.

“We kept records of our savings per month--how many hospital days we denied. If we had 100 requests for outpatient procedures and we granted 75, our director would list those 25 denials as savings.”

To further make the point, Penno offered this example:

“A young woman had a very bizarre and unusual stroke . . . and she was going through rehabilitation. She needed a voice machine to communicate her medical needs. The first question I was asked was ‘Is there any way we can deny this? It’s very expensive.’ I ended up approving it because it was medically necessary, but I got called on the carpet for it at a board meeting. . . .

“When I left the business, I noted that my work was like the job of directing customer service in a brothel--I knew what it took to do the job well, but there was something inherently wrong with the business.”

Lifetime Care

Georgia LeSire, a retired English teacher and mother of two grown children, joined the Kaiser plan during World War II--long before this kind of medicine was known as managed care. Her children, grandchildren and a great-grand-daughter were all delivered by Kaiser physicians. Her plan requires her to go to Kaiser offices, but provides coverage of all her medical needs.

“I joined in 1944,” LeSire said. “It only cost $3 a month at the time, and our company paid for it. I have been a member ever since. . . . I had multiple sclerosis in 1979. I’ve had arthritis. I’ve had eye problems. I’ve had foot surgery five times. My husband has had glaucoma and he’s had an eye implant. We’ve certainly taken advantage of our health plan. None of this cost anything.”

LeSire said that she has changed doctors only once, after her first doctor died.

“I’ve always had the specialists that I chose. . . . They pay for ambulances. They even pay if you get sick when you are out of the country.”

Each month, LeSire said, she receives a notice reminding her to be checked for her irregular heartbeat.

“It’s a fabulous thing to belong to. I never wait more than 10 minutes for an appointment. I can get an appointment and see my doctor on the same day if I have a problem. It makes you feel so comfortable, safe and secure.”

While proponents of managed care may have Clinton’s ear, when it comes time to judge the President’s health care reform plan, most Americans are likely to rely on their own experiences or depend on what they have heard from friends or relatives.

And if the stories told above are any indication, that means voters--and Clinton’s plan--are in for months of potentially agonizing soul-searching.