SAN DIEGO—Americans seem to agree that the health-care industry is in need of treatment. But not everyone believes that recent federal moves to legislate a patients' “bill of rights” is the right medicine.

Such legislation is misnamed, according to Dr. Jack Lewin, president of the California Medical Association.

“The bill passed by the Senate is an HMO Bill of Rights,” he said. “It puts power into the hands of HMOs [health maintenance organizations] and diminishes the power of doctors. As it stands now, patients might be better off if this bill were to go down in flames and President Clinton to veto it.”

Lauretta Sandles of Fairfield, Calif., can attest to an HMO diminishing the powers of her physician. In 1995, she became ill with a virus that attacked and enlarged her heart. She has been fighting HMOs for the last four years to approve the care she has needed. On a heart transplant list for 18 months, she began to improve with a new medication, but the insurer eventually disapproved it in favor of a generic brand.

During this period her original HMO was taken over by another, which in turn was bought out by a third insurer. The new insurer now has told Sandles that she cannot go to the medical center where her cardiologist practices, a mile and a half from home, but must drive to a county hospital 25 miles away.

In addition, the pharmaceutical committee of the HMO has notified her that she will be allowed to take the medicine prescribed by her doctor on a trial basis.

“Before,” said the mother and grandmother, who had worked her way to a top position in local government before her illness, “the only way I could prove I wasn't being helped by the generic drug was to die. It's all about money. It's not right for these companies to sacrifice lives for the bottom line.”

Keeping down the costs was precisely why HMOs had come into vogue. In the 1980s, as health insurance premiums escalated, private companies increasingly turned to managed-care providers to help hold down costs. A situation like Sandles' represents a downside of the managed-care system, critics believe.

Now, as Congress grapples with the problem, an array of issues must be faced. They include how to decide when a treatment is medically necessary, how to gain insurance coverage for treatments or prescriptions denied by health insurers, what legal recourse patients have when denied care or reimbursement for care, and how far the federal govern-ment's protection should extend.

A bill forged by Senate Republicans in mid-July promised to protect patients from health care insurers that skimp on medical coverage, for instance, those that make mastectomies a day-care surgery or refuse a request to consult a specialist. This protection, however, would be extended to fewer than 40% of people in managed care organizations, according to Wendy Mariner of the Boston University School of Public Health.

Further, “there is no enforcement mechanism in this bill,” she said. “There is no incentive for an HMO to abide by the regulation, such as giving patients the right to sue, and so patients will have little recourse if they don't receive the treatment they need.”

House Bill

A House health care bill authored in part by Democrat Reps. John Dingell of Michigan and Richard Gephardt of Missouri holds greater hope of meaningful reform, said Lewin of the California Medical Association. “I think their bill of rights would meet the expectations of both patients and HMOs.”

While still in early stages of garnering House approval, the Dingell bill has provisions relating to a patient's access to care, quality assurance, procedures for appeals and protections for the doctor-patient relationship. In the latter, patients would be assured treatments physicians deem medically necessary, be allowed to hold health plans accountable if its decision to limit care ultimately caused harm and be assured doctors could discuss all treatment options with them.

The major thrust of managed care reform, according to Mariner at Boston University, should be to “improve the accountability of insurers. They will tell you, however, that if patients have the right to sue their HMOs, it will drive up the costs of care because the insurance companies will be flooded with lawsuits. I don't believe this. It just doesn't happen in states where patients are now free to file suits. But by their protests, the insurers make it sound as if they are already guilty of negligence.”

Another factor, yet to be discussed, is quality of care, said Mariner, a professor of health law. “The question for patients is, ‘Are you getting [good health care]?’ And if you are, are you willing to pay for it? People have to realize that quality health care can't be had for cheap.

“A conscientious HMO can be put at a competitive disadvantage if it offers more and better care,” acknowledged Mariner. “That is why regulations can help competition; they level the playing field so that HMOs really can compete on quality as well as price.”

Doctor Knows Best?

John Airola, of Christian Brothers Employee Benefit Services in Romeoville, Ill., said that the patients' bill of rights approach sounds good, but asked, “What does it really mean?”

As a private Catholic health insurer for employees in Catholic institutions, the organization's Benefit Trust division provides its participants with the right to see a specialist without having to be referred by a primary care physician, as those in for-profit HMOs generally do.

“We don't like the concept of one person, a primary care physician, controlling a person's health care,” he said. “We think people know their needs and should be able to go straight to a specialist if they want.”

Some doctors would argue the point.

“Having a patient work with a primary physician provides better quality control for the patient,” said Dr. Jane Boyd, a physician at the Scripps Clinic in San Diego. “The role of a primary care physician is not to limit care but to coordinate it.

“Care can become quite fragmented when provided by multiple specialists without a primary physician acting, in a sense, as a quarterback. Also, many patients do not always know what conditions require specialty care or which specialists would ideally provide that care when needed.”

As legislators haggle over approaches to constructing managed care reform, their work, if Clinton approves it, will primarily affect the relationship between health insurers and their beneficiaries, said Jane Wilson of Catholic Healthcare West. “It won't interfere with the relationship between people and their doctors or hospitals,” she contended.

Her position is based on the work of California Healthcare West, which is a not-for-profit 48-hospital system in Arizona, California and Nevada. “By mission and ministry, we are driven to provide quality care to all patients, regardless of ability to pay,” she said.

The likelihood of any health reform bill passing this year is small, considering the complexity of the issue. According to Lewin of the California Medical Association, the issue will “come back next year and loom large in election year campaigns.”

Martha Lepore is based in Coronado, California.