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Page A-20 - The Second Half Playing
HMO HARDBALL, by Jack Broward |
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The Encinitas man has authored and published "How to Play HMO HARDBALL," a 145-page handbook for patient survival. The flicker of inspiration provided by Dr. Finney's "HARDBALL" patient protection manual, based largely upon personal and professional experience, grows in intensity as his "Patient Pressure" guidelines unfold in a case history analysis. The solutions develop as they are applied to the case studies of three patients who were victimized by HMO HARDBALL. Finney's wife, Jackie, was a childhood victim of polio who experienced dozens of surgeries. When she was wrongly denied referral by her HMO to an out-of-network physical therapist, the Finney pair went to work - as a team - determined and dedicated to design new approaches to their health care needs. "We knew we had to create a system by which patients could successfully fight the HMO system. We knew it would be precedent-setting in all our future HMO interactions," explained Finney, a 30-year career specialist in health care management in private as well as public agencies. "Denial of care is how the HMO system survives and prospers. The only certainty is that denial of care is never a one-time event," he emphasizes. "HMO HARDBALL" has unlimited innings and no timeouts. "The game never ends, except in your death," states the author, charging that, "HMO medical group executives successfully pressure doctors to do what's wrong. Our Patient Pressure System is designed to use pressure to persuade HMO doctors that it is in their self-interest to do what's right. "Pressure works," reasons Finney. "That's why HMOs, their doctors and lawyers use it." The Finney pair attended a funeral service in 1995 for a 39-year-old woman who died of breast cancer, because she was denied a simple mammogram to diagnose her symptoms. "We witnessed the devastating effects of the woman's death on her husband, three young children, her extended family and friends," Finney recalls. Subsequently, he says he and Jackie taught themselves how to play HMO HARDBALL, initiating their own system to apply pressure that is controlled by patients. In the absence of power over their patients, according to Finney, who was at one time a Greater St. Louis Health Systems Executive Director and a former manager of healthcare cost containment for Hewlett-Packard, "they become insecure and realize that it is not in their self-interest to wrongfully deny care. They become cooperative and will choose to "play HMO HARDBALL on patients who don't or won't play the game." The key to reversing this system is the conviction by HMO patients that they are "responsible" for their own health. This is pursuant to HMO declarations of patient rights and responsibilities with that understanding. And patients are simply pursuing their own health-care responsibilities by initiating a three-step procedure. It is simple, fill-in-the-blanks forms to impose insecurity on HMOs and HMO doctors who knowingly violate their patients' rights, according to Finney. The first step involves the initiation of an Advance Report Card (ARC). Not unlike the surveys conducted by HMOs when they query patients about their satisfaction with their HMO doctors following one of their visits, the ARC asks doctors questions about the effect of HMO financial consideration on their practice patterns -- before -- not after a visit. The ARC puts doctors on notice: Patients expect them to do what's right and to explain how they're going to provide good healthcare. "We have notified our HMO doctors exactly how their practices deviate from the HMO's own handbook and policies that require fairness, competency and advocacy. Our doctors have changed their practices, based on our submission of this document," Finney reports. He cites as an example, reminding his doctors that they are responsible for managing complicated medical problems, including specialist referrals and consultations to get the best diagnosis and treatment. "They now accept and fulfill their responsibilities to be our advocates, proving that our 'Patient Pressure System' is a counter force to HMO and medical group executive pressure on our doctors to ignore medical problems." The second step is activated, Finney explains, "When HMO doctors fail to base their diagnostic and treatment decisions on only correct medical facts. We send them the "Fact Attack," another fill-in form. "We do not personally attack our doctors, only their facts. This system has reversed delays and denials of tests, including colonoscopy, MRI, CT scans and DEXA (bone density), all based on our written presentation of facts." Finney's belief is that these reactions would not occur without patient pressure, noting that his process is responsible for his wife's success in gaining referral approval for out-of-network physical therapy. Finney states that he and his wife have never been forced to use the Patient Pressure System's third step, to formally appeal diagnostic and treatment decisions. "But we were able to use our education and experience in private and public sectors to prepare appeals that work for patients." The "ARC" and "Fact Attack" have been used to create and maintain an environment in which our medical care is based on medical facts and cooperation. "Moreover, these documents can be easily used by attorneys against the HMO and its doctors to win arbitrations and lawsuits," Finney asserts, illustrating three rigid "bottom line" rules by which HMOs operate. Rule One is that "HMOs promote hype, not health. Rule Two is that HMOs follow business plans, not health plans. HMO lawyers write contracts to protect HMOs and HMO doctors, not patients. The "boilerplate" language translates into never having to say you're sorry, much less admit that you're wrong. Rule Three is that "HMOs get sour when patients want power," the Finney pair determined after an exhaustive, 18-month evaluation of their own and other HMOs. Recalling the death of that woman who died of breast cancer in 1995 after their mutual HMO refused her requests for mammograms, the same assistant medical director who denied Jackie's referral was quoted in a lengthy obituary published by The San Diego Union-Tribune concerning the breast cancer victim. "He stated that our HMO was saddened by the woman's death," Finney recalls. "In reality, our HMO was saddened that it was forced to pay $525,000 to settle her malpractice suit." Before she died, the woman planned out her funeral service, requesting that several Bible passages be read at her service as "lessons." One passage, from the Book of Job, was read to the somber gathering by her spiritual advisor: "Oh that my words were now written! Oh that they were printed in a book!" "During the service," Finney notes in a forward passage contained in "HOW TO PLAY HMO HARDBALL," her eulogies emphasized that she had been a crusader for HMO patients' rights. Her obituary underscored how she had fulfilled her commitment 'to do anything I can to save the life of just one person.'" "The purpose of this book is, in some small measure," wrote Finney, "to reflect the lessons this patient heroine wanted to share with other HMO patients. The author hopes that she would have been pleased." Note: Readers who contacted me to find out where they can get copies of "How to Play HMO HARDBALL" following my initial column, August 31, are advised that orders can be placed at Amazon.com, through local book stores, and on HMO HARDBALL's website www.hmohardball.com.
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