Appealing Decisions

Your written response should be no less than 1.5 to 2 pages in length

This problem is adapted from a real case history developed by the Center for Health Care Rights in California .

• What procedural remedies does the patient likely have under private insurance and under Medicare or Medicaid?
• Are they adequate?

• Problem:

  Mr. H. was a diabetic and had severe ulcers on his feet. He was a member of an HMO, and his primary care physician had prescribed a treatment regimen that was proving ineffective. In response, the primary care physician offered Mr. H. an amputation below the knee that was his only option. Mr. H. went out of plan to a local wound care center that specialized in diabetic wound treatment where he was advised that vein by-pass surgery would likely take care of his problem. The HMO denied such surgery because Mr. H. referred himself to the specialist without permission. The HMO advised Mr. H.'s family that its utilization review department was reviewing the case, but that it would take at least a month to review. Subsequently, the HMO agreed to approve such surgery, but only if done by Mr. H.'s current medical group, which did not have any physician who had ever performed vein by-pass surgery. Mr. H.'s family asked for him to be transferred to a primary care physician at the medical group that staffs the wound care center. The HMO responded that although they sometimes approve such requests, they would not do so in Mr. H.'s case and that they had already granted enough of his requests. They gave as their reason a provision in the plan documents that prevent referrals outside the plan's network when the network's physicians have the capability to perform the required procedure

• Directions

• Complete the Exercise on page 360 of the text as an at least two to three page paper. Address each point below. Cite when appropriate from your text and/or other resources

  Assume you represent the interests of one of the following groups: physicians, low-income public, upper- and middle-income public, large insurance companies and HMOs, small employers, or large employers. Now, develop your legislative lobbying position with respect to each of the following reform ideas:

  1. A British type system
  2. A Canadian type system
  3. Filling the cracks in our present fragmented system by expanding Medicaid to cover all of the poor, requiring all employers to provide coverage for their workers, and requiring all self-employed individuals to buy their own private insurance
  4. An entirely privatized system that gives each person a voucher, funded by the government, sufficient to pay for 60 to 100 percent (depending on income) of the cost of the lowest-priced insurance policy in the market, and then leaving it entirely to individual choice whether and what to buy