Getting the services you need from an HMO often takes more than just a simple phone call. Convincing an HMO that you need a physician who understands diabetes care and that you need to be provided with up-to-date diabetes therapies, treatments, supplies, and equipment can be quite a daunting prospect. But it is possible, and it may be more straightforward than you think.
When Kriss Halpern, a lawyer specializing in the rights of people with diabetes, joined his first HMO, he was assigned to a physician with such a limited knowledge of diabetes it struck Halpern as laughable. “Unfortunately, I was his patient-I wasn’t laughing,” he says.
But Halpern is smiling now because his firm knowledge of proper diabetes care kept him fighting until he got what he needed.
Getting health insurance from a private health insurer as a type I diabetic is not easy. For Halpern, who was a self-employed lawyer when he went looking for insurance, it was impossible. Halpern had spent many years as part of the tight control group in the DCCT, and when the trial ended he was suddenly without healthcare. In order to avoid having to return to work at a big law firm, Halpern was forced to do some research.
He discovered that California runs something called the Major Risk Medical Insurance Pool (MRMIP). The organization provides insurance for all people rejected by private insurance companies because of their high-risk health status. (MRMIP can be reached by calling (916) 324-4695.)
Finding the Right Doctor
Halpern got insured through MRMIP and was assigned to one of its five affiliated HMOs, but the first physician he saw had very little diabetes experience. Halpern told the doctor about the DCCT and his own participation in the trial. He showed the doctor newspaper articles reporting the trial’s results, including a major story from the front page of the Los Angeles Times. The doctor wasn’t interested-he said that since Halpern was now a member of the HMO, Halpern would do what the HMO said was right. But Halpern replied, “I’m going to do what I’m telling you I know to be correct, and you’re going to help me.”
Halpern says the doctor didn’t like his attitude. “We agreed to disagree, and I requested a different physician. I got one. This time when I went back with the same articles, the guy said ‘Oh, OK, that sounds like a good idea, sure!'”
Getting the HMO to Provide
The DCCT proved beyond doubt that traditional care-infrequent BG testing and regulation-leads to an increased risk for every type of diabetes complication. “It’s not a theory anymore. It’s a fact. The DCCT proved it,” Halpern reminds us.
But despite this evidence, it can still be a challenge to convince an HMO to cover proper care. Halpern tried approaching his HMO with its own logic-an argument based on dollars and cents. Halpern told the HMO that if it paid for the kind of care that’s been proven to be correct, he wouldn’t get sick and they wouldn’t end up paying for his complications down the line. By providing him with proper care, they would save money.
The HMO refused to pay for his test strips.
“I told them, ‘Number one, you’re stupid, because it’s going to cost you in the long run when I get sick if I don’t test my blood sugar enough. And, number two, I think you’re wrong. I think in my contract [with the HMO], you are obligated to give me decent care. This is now proven to be the correct model of care. If you don’t give it to me and I get sick, I’m going to sue you.'”
Halpern’s letters and threats finally worked. A paper trail showing that you have demanded proper care and have been denied it is the last thing an HMO wants on hand in the event of a lawsuit. The threat of medical complications and of written documentation should work, Halpern says.
In order to buttress his appeal to the HMO, Halpern sent them hard evidence-abstracts from the New England Journal of Medicine describing the DCCT (Sept. 1993, Vol. 329, No. 14, pp. 977-986, and August 1994, Vol. 125, No. 2, pp. 177-188).
Support by Law
Legislation requiring HMOs to pay for correct diabetes care is in the works in several states. New York passed a law in January 1994, that requires most health insurance policies to reimburse patients for “diabetes self-management education, equipment, and supplies.” A similar bill in California, A-1335/S1014, has already been voted down, but with enough letters to legislators, the next time it comes up it could pass. Minnesota has also proposed a similar new law, Statute 62A.45.
In Halpern’s continuing search for the best possible care, he eventually joined Dr. Mayer Davidson’s well-known diabetes program at Mt. Sinai Hospital in Los Angeles.
“I got a little tough, I got a little demanding. I ended up with one of the best diabetes physicians in the country. You can do the same thing. You don’t need to be a lawyer to do it, you just need to open your mouth and tell them that this is what you want,” Halpern urges.
Halpern believes suing your HMO should be a last resort.
“You sue when you have no choice. If you sue, you’ve already lost. You’ve lost because you’ve already not received the kind of care that you need. You’ve lost because you might get sick while you’re waiting for something to happen with your lawsuit.”
Halpern sees hope on the horizon. “I believe it’s just a matter of time before these HMOs get it…but it won’t happen unless we continue to put pressure on them.”
This information is taken from a talk presented at “Taking Control of Your Diabetes,” a one-day “motivational conference and health fair” which took place in San Diego on September 23, 1995. Directed by Steven V. Edelman, MD, and facilitated by an impressive faculty of diabetes physicians, educators, researchers, and advocates, the conference addressed many important issues for people with diabetes. The conference was sponsored by the UCSD School of Medicine, The Whittier Institute for Diabetes, and the Veterans Affairs Center. Audio tapes of portions of the conference may be ordered by calling the Sound of Knowledge, Inc. at (619) 483- 4300.