Playing The HMO Game

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Now, like battle-scarred veterans back from the medevac front, patients are sharing their war stories on TV, in letters to Congress, in chat rooms and home pages on the Internet. When Helen Hunt ranted against the heartless HMO that was making life difficult for her and her asthmatic son in the movie As Good as It Gets, audiences cheered so lustily that the health industry's professional association felt compelled to launch a counterattack. It produced an ad for viewing in movie theaters that claimed Hunt's fictional son would have fared better in an HMO than in a traditional health plan; the screenwriters "got the facts all wrong." The multiplexes, knowing where their customers' sympathies lay, didn't want to show it.

The truth is, Americans are probably as healthy today as they ever were, and are paying less for their health coverage. Thanks at least in part to managed care, vaccination rates are up, premature births are down, more women are getting mammograms than ever before and costs have fallen dramatically. Managed care saved between $150 billion and $250 billion last year alone out of total U.S. health-care spending of $1 trillion. If things are really as bad as Hollywood and Washington say, the plan administrators wonder, why do more than three-quarters of their members say they are satisfied with their health care?

Good question. A TIME/CNN poll of 1,024 Americans conducted last week suggests that the country is of two minds about health reform. Although 85% responded that they were "very satisfied" or at least "fairly satisfied" with the quality of medical care they receive, 68% said they think traditional fee-for-service plans provide better health care than HMOs, and only 41% of those covered by managed care said they were "very confident" that their plan would pay for their treatment if they got really sick.

Getting really sick is what worries most Americans. They know how hard it can be to cut through the managed-care red tape for a pair of eyeglasses or a simple ear infection. What would happen, they wonder, if they or one of their loved ones became desperately ill and needed serious--and expensive--medical attention? Who would prevail if their medical needs ran smack into gate-keepers of an HMO focused primarily on reducing costs? The horror stories coming back from the front lines are not encouraging. A sampling:

--When Raymond Cerniglia's 13-year-old son Matthew developed a rare and aggressive cancer, doctors gave him a 20% chance to live and started an 11-month course of chemotherapy. Cerniglia's HMO paid the bills at first. But when things took a turn for the worse and doctors ordered a bone-marrow transplant, the health plan refused to cover it. The new treatment, the administrators said, wasn't a "medical necessity," nor was it on their list of covered therapies. Despite a letter from an expert at the National Institutes of Health testifying that this was Matthew's best chance at life, the HMO would not budge. Today Cerniglia, a computer technician in McLean, Va., is trying to scrape together enough money to pay for the procedure himself. His son's bills already total $100,000.