California Delivers On Patient Rights While Congress Talks; Announcement Today by Blue Cross Reflects California's Changing Marketplace.

Business Editors/Health & Medical Writers

SACRAMENTO, Calif.--(BW HealthWire)--July 10, 2001

As the Department of Managed Health Care (DMHC) and the Office of Patient Advocate (OPA) celebrate their one-year anniversary this month, the state official that oversees them says California patients are reaping the benefit.

Secretary Maria Contreras-Sweet of the Business, Transportation and Housing Agency, which oversees DMHC and OPA, says California is delivering "patient rights plus" while Congress considers its first step. She points to the announcement today by Blue Cross to stress care over costs as an example of the marketplace that's changing in California as a result of Governor Gray Davis' HMO reform.

Blue Cross, a unit of WellPoint Health Networks Inc. of Thousand Oaks, announced that it is departing from an industry practice of rewarding doctors for controlling medical costs. The insurer intends to scrap the incentive program in its HMO and instead link bonus payments directly to patient satisfaction.

"This is the direction we have been pushing HMOs to move toward," said Secretary Contreras-Sweet. "Blue Cross is to be commended for taking a major step forward in recognizing the primary objective of quality of patient care."

The month of July marks the one-year anniversary of the Department of Managed Health Care and the Office of Patient Advocate, which were created in 1999 out of Governor Davis' HMO reform package.

When laying the foundation for the DMHC and OPA, Governor Davis directed Secretary Contreras-Sweet to follow three principles: 1). Restore and affirm the primacy of the physician in medical decision-making; 2). Hold managed health care decision makers accountable for their decisions; and, 3). Guarantee that consumers have access to a second physician's opinion when medically necessary in critical or life-threatening situations.

By establishing the DMHC and OPA, California is at least two years ahead of Washington in patient rights. And, in the year Congress has spent debating the right to sue, California established a call center where HMO consumers experiencing problems with their HMO can turn. The phone number for California's HMO Help Center is 888/466-2219.

"Governor Davis' HMO Help Center is the centerpiece of the Department," said DMHC Director Daniel Zingale. "It's a place where patient rights enforcers -- backed up by physicians, nurses and patient rights experts -- are working to make sure that HMOs do the right thing and consumers get the quality health care to which they're entitled.

"Our goal is for public faith in the managed health care system to be so strong and quality so high that our HMO Help Center employees look like the Maytag repairman: sitting next to a silent phone, patiently waiting for a call for help."

Congress hasn't even discussed an HMO Help Center, another example of how California is leading the way in patient rights. "Patient rights without a help center are like public safety laws without police stations," says Secretary Contreras-Sweet.

California has established some of the toughest HMO laws in the nation. Secretary Contreras-Sweet praises DMHC Director Zingale for his department's tenacity in enforcing those laws. The DMHC has issued $1.5 million in fines, taken over failing health plans and uncovered patient rights law violations. Among the Department's major enforcement actions:

-- Enforcement of a $1 million fine against Kaiser Permanente related to the
death of one of its enrollees.

-- In May 2001, the Department took control of Maxicare because of concerns
about its ability to provide quality services to its 272,000 enrollees and
about its financial solvency.

-- In February 2001, the Department fined Pacificare $250,000 for late payment
of physician claims. Pacificare not only agreed to the fine immediately but
they worked with the Department to fix the underlying problems.

Secretary Contreras-Sweet also credits Patient Advocate Angela Mora for striking a careful balance as both a watchdog over the DMHC and as an advocate for consumers enrolled in an HMO. The Patient Advocate helps educate consumers about their rights and responsibilities as an HMO health plan member. She also helps them to learn how to best exercise their health care rights to ensure they receive the health care they are entitled under California law.