COMPLETE PHYSICAL AMERICA'S AILING HEALTH-CARE SYSTEM POKED, PRODDED IN PBS SPECIAL.

Byline: Valerie Kuklenski Staff Writer

Molly Mettler, a health-care consumer advocate, has a favorite term to describe the current state of American health care: fubar. In its polite translation, that's short for ``fouled up beyond all recognition.''

It's a view most people don't come to until they are forced by illness or injury to interact with doctors, hospitals and insurance companies beyond routine checkups and regular payment of premiums.

The extent of the problem is detailed in ``Critical Condition With Hedrick Smith,'' a three-hour PBS special airing at 8 p.m. Wednesday. It includes a look at the Community Health Foundation of East Los Angeles Inc., a clinic struggling to meet the needs of its mostly uninsured community.

``Critical Condition'' isn't a policy debate; Smith is leaving that turf to the politicians and pundits arguing the patients bill of rights and other broad concepts of the future. Instead, it looks at specific individuals' cases, people whose maladies and dealings with the system represent thousands or millions more like them. His goal throughout the 2 1/2-year project was to keep the consumer's viewpoint.

``We had no hypothesis, we had no background, we had no theory, and we had no ax to grind,'' Smith says. ``We had the disadvantage of not knowing the terrain, but we had the advantage of not knowing the terrain. We had the advantage of not being committed to any particular viewpoint.''

Smith, who executive produced and anchors the program, says he and his team were stunned by some of their findings, as they expect many viewers will be:

--At least 44,000 and up to 98,000 people die each year due to medical errors in hospitals - more than the number killed by auto accidents, AIDS or breast cancer.

--There is scant public record of medical errors and few ways for consumers to evaluate a doctor or institution's success with, say, open- heart surgery.

--There are wide discrepancies from one doctor and hospital to another in how to treat the same patient.

--More than 100 million Americans are coping with chronic conditions, racking up $760 billion a year in health-care costs - three-fourths of America's total health-care bill - and they are in danger of having the insurance rug pulled out from under them.

--85 percent of 44 million uninsured are working Americans who have no group insurance on the job or who can't afford the premiums. (Los Angeles County, with one in three residents uninsured, has the largest concentration of people without health insurance in the country).

``Critical Condition'' zeroes in on Louisville, Ky.-based Humana Inc., as an example of the price patients often pay for membership in a for- profit insurance organization.

To its credit, Humana has implemented a disease management program in which nurses routinely contact members with ongoing conditions such as congestive heart failure, keeping tabs on their medication, weight and symptoms - thereby cutting down their trips to the emergency room, which keeps both Humana and the patients happy.

But Humana appears downright stingy when it comes to shelling out for expensive treatments. For example, one woman with breast cancer in Tampa, Fla., quit Humana's Medicare HMO for another plan after Humana refused to pay for treatment at the highly regarded H. Lee Moffitt Cancer Center. Helen Boone's case is typical in Tampa, where Humana is the largest health-care provider but locks most of its members out of Moffitt.

``Not everything that is medically necessary is covered by the insurance plan,'' Dr. Jerry Reeves, then Humana's chief medical officer, told Smith. ``And that's a fact of life that we all have to get accustomed to.''

Dr. John Ruckdeschel, Moffitt's director and CEO, suggested for-profit HMOs like Humana come out ahead when a patient quits the HMO because it won't cover a certain treatment or procedure.

``If I were a Medicare HMO, what I would hope is that you paid all your premiums, did everything you told me you were going to do, and as long as you were not sick, you were fine,'' Ruckdeschel says in the program.

``But the minute you got sick, you say, 'Goodbye, I'm out of here.' I've taken your money to ensure you that I'll take care of you when you get sick, but when you got sick you didn't want me, so you went somewhere else. Guess who won? I mean, that's a wonderful racket, from my point of view.''

Kaiser CEO David Lawrence told Smith that for-profit HMOs are going after the healthier segment of the population, leaving the burden of higher-maintenance patients to nonprofits like Kaiser and government-run hospitals.

Pretty discouraging stuff, by itself enough to make a viewer want to check into a hospital for treatment of depression - if only it were covered. But Smith balances those subjects with good news where he found it:

--The Lexington, Ky., Veterans Administration Hospital, which decided to be up-front with patients and their families about medical errors and - as a result, has seen a decline in its legal liabilities rather than the increase feared by private sector hospitals.

--InterMountain Health Care in Salt Lake City has saved an estimated 50 lives a year since it began closely tracking outcomes from various pneumonia medications and establishing standardized treatments.

--The huge nonprofit HMO Kaiser Permanente succumbed to pressure from San Francisco AIDS activists in the mid-1990s and began reaching out to those concerned about AIDS and HIV, not merely with educational prevention programs, but by asking for their input and funding patients' very costly, newly approved medicines.

--Government-funded safety-net programs in Tennessee and California help the uninsured get treatment they otherwise could not afford, allowing them to concentrate on recovery rather than the prospect of crippling debts.

Smith, a Pulitzer Prize-winning veteran of The New York Times, says working on ``Critical Care'' influenced his own decisions.

``I can tell you, as a result of my work on this series, I've changed the way I get my health care,'' he says, noting that his doctor's retirement forced Smith and his wife to shop around the Washington, D.C., area.

Instead of simply looking for the best internist in Washington or Chevy Chase, Md., he looked higher up the chain to the hospitals and settled on the renowned Johns Hopkins Medical Center, then chose a doctor with admitting privileges there.

``That's an hour's drive. It's not convenient, but it's the best, best health-care system in my region,'' Smith says. ``I moved my health-care practice to a geographically inconvenient site in the belief that, if something really serious happens to me, that's where I want to be cared for.

``I never would have done that before doing this series.''

Mettler, senior vice president of Boise, Ind.,-based Healthwise Inc., a nonprofit consumer advocate organization, says patients' ability to make informed decisions is vital to reform. ``The patient is central to health care - consumers' knowledge, their hunches, their questions, their ability to seek out as much about their situation as possible.''

She says the health-care issues will not go away anytime soon, because of the graying of the baby boomers and greater expectations raised by more sophisticated medical and surgical treatments.

``Someone is turning 50 every 9 seconds,'' Mettler says. ``If you think of what it is to turn older, you're not dealing with scrapes and sports injuries as much as you are chronic illness.

``You think, 'Oh, I've been healthy and I've been getting pretty good care and this isn't a big worry for me.' Well, heads up - it will be.''

``CRITICAL CONDITION''

What: Hedrick Smith looks at the health-care system in America from a patient's perspective.

Where: KCET.

When: 8 p.m. Wednesday.

CAPTION(S):

4 photos

Photo:

(1 -- cover -- color) What's Ailing us?

America's health-care system fails its physical

(2) 'We had no hypothesis, we had no background, we had no theory, and we had no ax to grind. We had the advantage of not being committed to any particular viewpoint.'-Hedrick Smith

Pulitzer Prize-winning journalist and host of PBS' ``Critical Condition''

(3) Dr. Catherine Egli, a pediatric diabetes specialist, gives 11-year-old Dillon Moore his quarterly checkup for diabetes. Dillon's health plan supplies a $5,000 pump.

(4) Valerie Kennedy of Chicago tells ``Critical Condition'' host Hedrick Smith of her shock at discovering at the age of 37 that she had breast cancer.