Quality Gap
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Chronically Ill
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Idealisitic HMO
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By Ariadne Allan

The program begins with a look at chronically ill patients struggling to receive coverage for the care they need in today's cost conscious health care market. From birth to old age, these patients represent over 100 million Americans living with some kind of chronic condition. At a cost of $760 billion a year, they pose a major challenge to commercial insurers, like for-profit Humana, in their largest market, Florida, where the program opens.

In Tampa, Mike and Criss McConnell fight to hang on to home health care coverage for their son Hart. Born with a hole in his diaphragm, Hart needed a machine to breathe, and 24-hour care for almost two years. Forced to take over all of her son's care, Criss admits "I was beyond terrified."

The McConnell's story reveals the tension between commercial insurers like Humana, and chronic patients. Notes University of California health economist Hal Luft, "if you enroll a lot of people who are very high cost, you can end up spending more than what you bring in, in premiums, and you won't be able to stay in business very long." Humana's Dr. Jerry Reeves, then senior vice president, acknowledges the conflict, "Investors want a profit. And whether it's for profit or not for profit, you still have to have something left at the end of the year to still be here next year."

To cut costs for some of Humana's sickest members, the company turns to disease management for its congestive heart failure patients. While the program cuts mortality in half it also slices hospital costs by as much as seventy-eight million dollars and emergency visits by 60%.

The program has helped people like Jeanne Lange, a retired schoolteacher with congestive heart failure, avoid expensive emergency room visits. Under this approach, a disease manager, Pam Robinson, will call regularly to keep her healthy and on track, adhering to a low sodium diet. Pam's job is to check to make sure prescription dosages are up to date, and that the patient takes them. Even though the program is designed to prevent emergency admissions, the nurses encourage patients to seek medical care before a crisis erupts. That helps Humana's bottom line.

But that strategy does not pay off for all chronic conditions, so Humana has to make choices. In Palm Beach, we see deputy sheriff Mark Chipps lose extended benefits covering special therapies for his daughter Caitlyn who suffers from cerebral palsy. Humana's action prompts Chipps to wonder if a trade-off is being made. "You can't get rid of these kids and just weed them out," he complains so that you save money - at the same time centering all your attention on these other 'older' folks."

Unable to pay out-of-pocket for the therapy Caitlyn once received through Humana's programs and strapped financially, the Chipps had to reduce Caitlyn's therapy, and her condition worsened. "My wife and I both noticed that she became very frustrated on the computer. She was having a lot of problems just walking. She was constantly holding on to things for balance, falling into walls, falling down." But Humana denied that it was cutting out children to spend it's money on other programs such as congestive heart failure. Chipps protested, charging "it's cost over care, cost over care." He filed suit against Humana and won.

When medical decisions have to be made while considering cost factors, the type of care patients receive can drastically differ. Two Fort Myers area seniors grappling with life after suffering strokes, struggle to overcome paralyzing disabilities. The program follows two patients, Marijane Schacherer, who enters an acute inpatient rehabilitation hospital, and Anthony Oczkowski, whose Humana Medicare HMO will only pay for his recovery care in a less expensive skilled nursing facility, overruling his doctor. Dr. Andy Kramer, of the University of Colorado Center on Aging, has studied stroke and the outcomes of different treatments. His studies show that inpatient rehabilitation pays off much better than nursing home care in the long run -- with a significantly better return to normal living.

Most people pick their health plan when they are healthy, comparing costs for routine doctors' visits or prescriptions. But when a life threatening illness strikes, like cancer, they are forced to look beyond the basics.

Patients like 37-year-old Valerie Kennedy, a runner and vegetarian, and Helen Boone, a 75-year-old grandmother who "never thought about cancer," quickly learn about the importance of accessible specialty care after being diagnosed with breast cancer. Their hometown of Tampa boasts Florida's only National Cancer Institute designated cancer facility, the H. Lee Moffitt Cancer Center and Research Institute. Yet for many Humana managed care patients, the specialty hospital is out of reach -- excluded from the insurer's provider network. Explaining why Moffitt is not available to all of their patients, Humana's Dr. Reeves says, "we don't believe that 100% of all patients who have mild stage cancer must go to Moffitt in Tampa."

From chronically ill kids to cancer patients, in today's cost-driven health market, the financial objectives of commercial health insurers like Humana sometimes put them at odds with the people who need them most. When cost and quality of care collide, for-profit health plans can block doctor's orders and deny certain kinds of care.

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