Health Care News
Gunning the HMOs
How much of John Q is true?
by Vicki Lankarge
The new movie John Q, an HMO bureaucrat played by actress Anne Heche refuses to place the main characters son on a waiting list for a heart transplant because his underinsured family cant come up with the downpayment on the $250,000 operation. She urges them to take the boy home and make what remains of his life comfortable. People get sick, she says. They die. Thats the way it goes.
Fact or Fiction?
Health insurers are Hollywoods hottest new villains. But the managed care backlash that fuels this movies momentum (John Q takes the hospitals emergency room hostage at gunpoint) is something of a paradox.
A 2001 study by Harris Interactive found that while people say they dislike managed care, most consumers also say they are happy with their own health plans. How can that be true ifas this film suggestshealth insurers are routinely denying care to catastrophically ill patients because they dont make enough money and lack the right coverage?
Some say its because most people enrolled in health plans are healthy. Id bet if you interviewed people who have a chronic illness and use their health plan much more often than healthy people, youd find very different numbers in the satisfaction category, says Richard Sorian, a senior researcher with Georgetown Universitys Institute for Healthcare Research and Policy.
Could it be that the health insurance industry works better than the publics perceptionand Hollywoods latest stinging portrayal?
Thats exactly what the BlueCross and BlueShield Association (BCBSA) is saying. There are dozens of organizations in the United States that work with the catastrophically ill or injured and transplant patients, according to BCBSA Chief Medical Officer Allan Korn. Its inconceivable that a health care professional would not be assigned to the characters in this movie to assist them clinically, as well as locate financial assistance and other support, says Korn.
Patricia Kolff, director of the National Transplant Assistance Fund (NTAF), disagrees. Dozens [of organizations]? Who are they? Kolff asks. There are certainly disease-specific organizations that offer support, but extremely few that offer financial assistance on a nationwide level. No doubt about it, it is a reality that some people cannot receive a transplant if they do not have appropriate financial coverage.
Are You Covered?
While debate rages around how much of John Q is true, do you know what your health insurance plan would cover in the event you or a family member needed treatment for a catastrophic illness or injury, or a transplant? If youre tempted to think it can never happen to you, consider this: You have a one in five chance of becoming disabled due to an accident or illness, according to the U.S. Census Bureau.
Unless youre one of the 39 million Americans who are uninsured, you and your family have health insurance through an employer, a government agency such as Medicare, the military, or an individual health insurer. Benefits under such policies can vary greatly and they depend on a variety of factors, including state laws.
Additionally, consider these facts:
- Insurance caps: Many health insurance policies place a limit on the total amount of money they will pay out during your lifetime. After you have reached the limit (typically $1 million, but it can be much less), you have no more insurance. From then on, you are financially responsible for your treatment. Some policies also put caps on how much they will pay for a specific procedure or treatment.
- Experimental procedures: Many health insurers will not cover certain transplant procedures or treatments for catastrophic illness or injury that they consider experimental. Make sure when your doctor prescribes a treatment that it is covered by your health plan before you receive the treatment. If your health insurer wont cover the procedure or treatment, you have the right to appeal.
- Loss of health insurance: Once people become seriously ill or injured, their problems are often compounded by the loss of their health insurance. Some lose their health insurance when they lose their jobs and are not eligible for continued coverage under COBRA. Others cant afford to keep paying their premiums because their medical conditions are so expensive.
Programs for Help
- High-risk health insurance pools: High-risk health insurance pools are special programs created by state legislatures to provide health insurance for people who cant get coverage anywhere else. Each state operates its high-risk pool differently, although many share common features.
- Medicaid: Medicaid is a jointly funded federal-state health insurance program that covers approximately 36 million low-income individuals, including families with children, the elderly, the blind, and the disabled. Some states also have a medically needy program in which Medicaid eligibility is extended to higher-income patients who have high medical costs.
- Medicare: Medicare is a federal health insurance program for people age 65 or older, certain younger people with disabilities, and patients with end-stage renal disease. According to the Centers for Medicare and Medicaid Services, Medicare serves about 40 million beneficiaries.
Who Else Can Help?
Even when you have insurance, its easy to underestimate the huge burden a catastrophic illness or injury can put on your financial resources. There are often lifelong costs associated with these, including prescription drugs and often-overlooked costs, such as travel expenses for treatment and possibly lodging for those who have to visit transplant centers out of their normal driving range.
Many patients wind up mortgaging their homes and using loans and their savings to subsidize their medical treatment, according to Kolff, who co-founded the NTAF in 1983 with her husband, cardiac surgeon Dr. Jack Kolff.
Based in Pennsylvania, NTAF provides a variety of services to patients who need transplants and those suffering from catastrophic illness or injury, such as brain damage suffered in a car, sledding, or diving accident.
The nonprofit organization offers modest ($1,000) medical-assistance grants to eligible candidates to help offset immediate treatment-related costs such as relocation, medications, home care, and transportation. It also helps patients establish restricted transplant accounts that allow contributions to remain tax deductible to the extent of the law. NTAF administers these accounts and retains four cents of every dollar raised to defray general office costs and to implement patient services.
Since its inception, NTAF has raised $17 million for patient assistance. According to Kolff, about 2,000 people request information from the organization each year and approximately one in five begin the fundraising process. If a patient dies before receiving an organ, NTAF retains the funds for grants to other patients.
Kolff estimates NTAF is currently serving 700 patients who are fundraising for their heart, heart-lung, lung, kidney, liver, pancreas, bone marrow, and stem-cell transplants, as well as catastrophic brain and/or spinal cord injuries.
Patients and their families shouldnt be afraid to ask for help, says Kolff, and they should pursue every avenue available for assistance. Hope is also important, even when the financial safety nets are failing. Everyone has some support system available to them, she says. Its just a matter of helping them to identify it.
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