Taking a Pulse

A pilot project that allows Sacramento-area consumers at odds with their HMOs to seek help from an ombudsman advisor is attracting national attention as a possible remedy to widespread public concerns about managed-care plans.

The privately funded project is the first to systematically track patients’ problems with their health plans and to determine what role an ombudsman can play in aiding consumers.

The 9-month-old Sacramento program is being closely watched by health-policy experts as Congress and many states consider legislation to tighten oversight of the fast-growing managed-care industry. Several consumer-protection bills pending in Congress and in the California Legislature would mandate ombudsman programs for HMO enrollees.

The concept won big boosts when President Clinton’s special commission on managed-care endorsed an ombudsman-type program, as did a similar health-insurance panel formed by Gov. Pete Wilson in California.

Several influential HMOs, including Oakland-based Kaiser Permanente and Seattle-based Group Health Cooperative of Puget Sound, also have endorsed the use of an “independent, nonprofit” ombudsman.

“There’s a lot of buzz now that the ombudsman concept is probably one of the most important consumer protections,” said Larry Levitt, a program director at the Kaiser Family Foundation, one of three health charities funding the Sacramento program. The other sponsors are the California Wellness and Sierra Health foundations.

The health-insurance industry vehemently opposes tough regulatory measures proposed by congressional Democrats that would, for example, allow consumers to sue HMOs for damages under state law for wrongful death or malpractice. The industry--and some Republican leaders--contend that such laws would raise medical costs and make health insurance less affordable.

Some observers see the ombudsman idea as a less controversial reform that could be acceptable to all sides. “We’re hearing rumors that an external appeal mechanism is an obvious compromise for the managed-care industry,” Levitt said.

The Sacramento project got underway in July under the direction of the Los Angeles-based Center for Health Care Rights, a patient advocacy group. One of the project’s first moves was to commission an independent study that found that 27% of Sacramento-area consumers had reported a problem with their managed-care plan in the last year, said project director Peter Lee, an attorney for the group.

While it may be expected that a significant number of consumers would experience some problems, a more troubling finding was the number of people who reported that their problems were “major,” Lee said.

About 11% of those surveyed said they experienced major problems that cost them at least $200 in out-of-pocket expenses, caused them to miss at least 10 days of work or led to a worsening of their health, Lee said.

Lee said the most common complaint involved delays or denials of medical care or disputes over which benefits were covered. The second-most frequent complaint was an inability to get timely doctor appointments or inadequate access to specialists.

“There is a very significant pool of people in managed care who are having difficulties making the system work for them,” Lee said. “The outstanding question is how well managed care is doing in resolving these problems.”

Lee said about 1,000 consumers have contacted the ombudsman program, which includes a toll-free hotline and counselors who help the public with managed-care questions. The program is open to Sacramento-area residents with all types of private and government-paid insurance, including Medicare and Medi-Cal beneficiaries.

The project is collecting data on the number of complaints registered against each HMO, as well as demographic data about those individuals seeking help. The program will make this information available to the health plans in the next few weeks, and plans to issue a public report in late June, Lee said.

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David Olmos can be reached by e-mail at david.olmos@latimes.com or by fax at (213) 237-7837.

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A Look at Managed Care

A survey conducted for a Sacramento ombudsman program found that the majority of managed- care consumers had experienced no problems with their health plans in the previous year; 27% said they had.

Problems

Among the residents who reported problems, the three most commonly cited issues were:

* Delay or denials in authorization of care or disagreements over what benefits were covered by the health plan (42%).

* Limited access to physicians, including difficulty getting appointments or access to specialists (32%).

* Quality of care, including members’ perception of inadequate or inappropriate medical treatment, diagnoses, facilities, or difficulty obtaining test results (11%).

Consequences

Asked about the consequences of their problems, respondents’ most common answers were:

* Problem financial loss (30%).

* Lost time from work, school or other major activities (31%).

* Worsening of medical condition or development of a new health problem (11%).

Source: Lewin Group survey conducted for the Kaiser Family Foundation, California Wellness Foundation and Sierra Health Foundation.