Friday, October 16, 1998



HMSA denials nearly cost
Paauilo man his life

'It was a clinical judgment based on
the best information we had
available to us, ' says HMSA

By Helen Altonn
Star-Bulletin

Tapa

Dealing with cancer wasn't as painful for her husband as was the feeling that he wasn't worth the expense of treatment, says Melani Mendes of Paauilo on the Big Island.

His doctors requested a medical procedure that was denied four times by the Hawaii Medical Service Association, she said.

"He said, 'You know what it's like to have people deny medical treatment? They're telling me I'm not worth help. I might as well start preparing to die,'" she said.

HMSA ultimately paid all expenses, but not until after the couple spent their own money to go to Texas for medical help.

Mendes said her husband, Lloyd, 49, had had surgery three times in his neck for what was believed to be recurrent parathyroid cancer.

Five doctors agreed a magnetic resonant imaging study was needed to pinpoint the cancer.

Despite doctors' requests, HMSA refused to cover an MRI because medical directors gave an opinion "that an MRI would not detect recurrence of metastatic parathyroid cancer . . . "

Mendes said her husband's doctors -- Niranjan Rajdev, Sharon Vitousek, Alfred Liu, John Dawson and Jeanette Abel -- were flabbergasted.

Rajdev, a hematologist and oncologist, wrote an appeal to HMSA, Mendes said. Doctors at the M.D. Anderson Cancer Center in Houston were "very moved" by the letter, she said. "They told us they couldn't believe HMSA would continue to deny his plea for a test they had been using for years."

Rajdev said, "If you're dealing with patients' lives, you need to have doctors involved" rather than people who may not have all the information necessary to make a decision.

He added, however, "In all fairness, I've been able to get through most of the things I need and most medical directors are receptive . . . In the trenches here, we don't have time for a grievance process, especially with cancer."

After three HMSA denials to cover an MRI, the Mendeses talked to their doctors about going to the cancer center in Houston. The center reviewed the reports and tests and agreed to help.

An MRI was done on Mendes immediately after they went there in May last year, Mendes said. Two days later, surgery was done to remove a cancerous parathyroid gland from her husband's throat and a cancerous tumor from his chest, she said.

"If they had done exploratory surgery in the neck (the only option without an MRI), they would never have found it in the chest."

Rajdev said Lloyd Mendes has some disability from his pain but he doesn't see any recurrence of the cancer. "We just have to monitor him, like before. If we hadn't done this thing in time, it could have been a lot worse."

Melani Mendes said HMSA denied their request for an MRI for the fourth time while they were in Houston.

Still, Lloyd Mendes said, they spent a lot of money on air fares and living expenses in Houston.

The couple, which has a family ranch, spent seven weeks in Houston during the surgery and returned for seven weeks for radiation treatment.

HMSA spokesman Fred Fortin said the MRI request was denied "after a very extensive review process that was overseen by a respected neurosurgeon and a general surgeon, as well as consultation with radiologists and an ear, nose and throat doctor. There were four denials simply because there were four requests to reconsider the situation."

He said, "A medical judgment was made by those directors who consult with us that this (MRI) was not appropriate in this situation . . .

"It was a clinical judgment based on the best information we had available to us. That eventually proved to be wrong in this situation. That happens and it was very unfortunate."

HMSA ultimately paid for the MRI because of new information from the Anderson center, Fortin said, "and we had some consideration for the member here, simply because of the process that had gone on . . .

"While it was painful, I think we have done the right thing in the end, and that's hopefully important as well."

"What was difficult was fighting so hard," Melani Mendes said.

She believes a patient rights law would have made a big difference in their insurance battle. "We would never have gone to M.D. Anderson. We would have appealed it (HMSA's decision) right here and would have done it immediately after the first denial."

A patient rights bill was passed by the Legislature and signed into law by Gov. Ben Cayetano July 15.

That was her husband's last day of work as a county highways division supervisor, Mendes said. He retired on a medical disability.

He said his right shoulder is always in pain; he tires when walking and has difficulty driving. He said, "Everything is going good. If my blood count stays down, everything is OK."


Health coalition allows
public to have a say
in medical care

By Helen Altonn
Star-Bulletin

Tapa

For $5 a year, Hawaii residents may help influence the kind of medical care they receive.

That's the public fee to join the Hawaii Coalition for Health, a nonprofit advocacy organization for patients. Physicians pay $150 a year; nurses and other health professionals pay $25.

"We really feel like the public needs to get more involved, to have a voice and make use of the services, which will lead us to expand services," said Dr. Arleen Jouxson-Meyers, coalition president.

A pediatrician and University of Hawaii law student, Jouxson-Meyers founded and incorporated the coalition in December 1996.

"She was a student in my tort class before I retired," said Richard Miller, former law professor. "I got a call one day describing what she was doing, asking if I would serve as a consultant . . . I figured, 'Why not? Nothing much is going to come of this but, what the heck, it sounded interesting.'"

In two years, Miller has seen one coalition victory after another -- "against all odds."

The first thing that captured his interest, he said, was a proposed Hawaii Medical Service Association participating physicians' agreement.

"It was as close to an agreement for slavery as any I've seen," Miller said, "with virtually no rights for a physician, and they (HMSA) had the ability to virtually terminate them at will."

HMSA made some significant changes in negotiations with the coalition, Hawaii Medical Association and Hawaii Federation of Physicians and Dentists. Only a two-year agreement was signed so work could continue on troublesome areas.

State Insurance Commissioner Rey Graulty said the coalition has "changed the environment in which the medical profession, and hopefully other providers, interact with the insurers, be it HMSA, St. Francis or anybody else who would like to avail of the doctors' services."

"It is to their credit and to the benefit of all doctors and to patients, because doctors able to work without restrictions in the best interest of the patient are able to do the most good for the patient," Graulty said.

Many physicians joined the coalition as it gained visibility in the fight over HMSA's doctor contracts, Jouxson-Meyers said.

While it isn't perfect, she said, "HMSA's participant contract at present is the best in use in Hawaii."

Although the coalition made headway, Miller said, "it occurred to me only by getting some legislation could we deal effectively with the problem."

That led to the discovery that HMSA is a mutual benefit society that isn't subject to the insurance commissioner's scrutiny except for solvency, he said.

The new patient rights bill remedies that, Miller said. Told the bill "wouldn't fly," he attributed its passage to the political forces of the coalition and American Association for Retired Persons.

The coalition was involved in planning a workshop on managed care being held today through Sunday at the Hilton Turtle Bay Resort.

Jouxson-Meyers formed the coalition with three directors and 38 consultants. It now has about 950 members.

Differences are bound to occur because the coalition would like to see costs contained so more people can be insured, Miller said.

"This is going to come head on with physicians' desire to have their income unimpaired," he said.

Jouxson-Meyers said the coalition plans to write a comparative analysis of all health plan provider contracts, which are "really the key to what a physician is able to do for his or her patient. It's not a physician issue. It's a patient quality of care issue."

The coalition offers to help health plans improve their provider contracts from the patient's perspective, which takes a lot of work and resources, she said.

It maintains a hot line -- 622-2655 -- open 51/2 days a week during business hours. "We will try to answer any health-related question," Jouxson-Meyers said.

Both the coalition and AARP will provide information on the patient rights bill and help people through the appeals process when it begins.

The coalition also has started a monthly one-page publication called "Health Tip," with 8,000 copies being distributed statewide by Longs Drugs and Costco.

Jouxson-Meyers, Miller and other coalition members spend much time on committees working on health issues, such as patient confidentiality of medical records and alternatives to QUEST.

Those activities will have to be curtailed if the coalition doesn't get more public members and support, Jouxson-Meyers said.

"In my opinion that will be a real loss to Hawaii's people. Undoubtedly, we are the watchdog in health care issues in Hawaii."



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