Quality Gap
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Chronically Ill
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Idealisitic HMO
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Uninsured
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OPEN:

ANNOUNCER: This program is part of the PBS Democracy Project.

b-roll: ambulance lights/EMT’s tending patient in home:

EMT 1: I understand that you’re having some chest pains?

EMT 2: OK. We’re gonna take your blood pressure here.

LUCA FRESIELLO: I thought it was just a bad dream. I really couldn’t believe anything could, could happen like that. Really.

EMT 1: And the strap’s gonna to go under your arms.

VALERIE KENNEDY: I’d never been in the hospital. Gee, I was the healthiest, you know, woman walking around. . .

b-roll: stretcher into ambulance

EMT 3: Let’s go.

VO/OC

JAY LUBBERS: It’s something like falling off a cliff and you don’t know when you’re going to hit bottom.

Cue music

b-roll: pov - ER hallway

ER Nurse 1: Are you still having chest pains?

ER Doctor: Can you just describe the chest pain for me? Was it a sharp pain? Was it a dull pain?

NARR: ALL OF US. WE’RE ALL AFRAID OF WHAT WILL HAPPEN WHEN OUR HEALTH FAILS.

b-roll: pov — ER exam room

ER Doctor: Alright. What’s his vital signs right now?

NARR: WITH SO MUCH AT STAKE, JUST HOW GOOD IS YOUR HEALTH CARE?

ARTHUR LEVIN: Medical errors kill between forty-four thousand and ninety-eight thousand people a year in the United States.

MIKE McCONNELL: If the insurance company denied anything he could die.

MARK CHIPPS: It’s money. It’s cost over care. Cost over care.

MARK CHASSIN: As a consumer, you’re highly likely to be the victim of a quality problem, and not know it.

title logo

NARR: CRITICAL CONDITION WITH HEDRICK SMITH

ANNOUNCER: Principal funding for Critical Condition was provided by

The Robert Wood Johnson Foundation.

Making grants to improve the health and health care of all Americans.

Major funding provided by

The California Healthcare Foundation.

Additional funding provided by

The Rockefeller Brothers Fund

And the Charles E. Culpeper Foundation.

Title/bumper

Dip to black

STANDUP: NO ONE TESTS THE QUALITY OF AMERICAN HEALTH CARE MORE SEVERELY THAN THE CHRONICALLY ILL…BECAUSE THEIR NEEDS ARE SO DEEP AND LONG-LASTING.

AS WE AMERICANS LIVE LONGER, MORE OF US HAVE CHRONIC CONDITIONS. SO THAT TODAY, MORE THAN 100 MILLION AMERICANS - SOMEONE IN EVERY THIRD FAMILY - IS LIVING WITH A CHRONIC CONDITION SUCH AS CANCER, STROKE, DIABETES, OR HEART FAILURE.

THREE QUARTERS OF ALL U.S. HEALTH CARE DOLLARS -- $760 BILLION A YEAR -- ARE SPENT ON THE CHRONICALLY ILL.

SO FOR MANAGED CARE, NOW OUR DOMINANT FORM OF HEALTH CARE, THE QUESTION IS: CAN THOSE COSTS BE CONTROLLED WITHOUT SACRIFICING QUALITY OF CARE OR PUTTING AN UNFAIR BURDEN ON PATIENTS AND THEIR FAMILIES?

NARR: WE BEGIN OUR REPORT IN FLORIDA — WITH ONE OF LIFE’S MOST JOYOUS EXPERIENCES. CHILDBIRTH.

b-roll/nat sound: Hart’s birth

Mike McConnell: Aww

Doctor: The baby’s out.

Mike McConnell: Aww.

CRISS MCCONNELL (v/o): When he was born and they held him up, he was so beautiful that he took my breath away. He was just so beautiful.

Heart BirthNARR: BUT FROM THE VERY FIRST MOMENT, HART MCCONNELL’S LIFE WAS PRECARIOUS. HE HAD A LIFE-THREATENING BIRTH DEFECT: A HOLE IN HIS DIAPHRAGM.

MIKE MCCONNELL: The crash cart was in the labor room because, it was known that as soon as the cord was cut that he becomes critical.

NARR: CRISS AND MIKE MCCONNELL WERE GIVEN A POOR PROGNOSIS FOR THEIR SON HART...

CRISS MCCONNELL (o/c): The very best that anyone could give us as his chance of living was 50/50.

b-roll of Hart lying amidst tubes & machines

NARR: JUST TO STAY ALIVE, HART NEEDED A MACHINE TO BREATHE ...AND PUMP OXYGEN INTO HIS BLOOD.

MIKE MCCONNELL (v/o): He had a machine that was taking the blood out of his neck, oxygenating it and cleaning and putting it back into his neck to rest his heart so he could hopefully enhance his chances of survival.

NARR: FOR CHILDREN LIKE HART, MEDICAL INSURANCE IS CRUCIAL — ALMOST NO ONE COULD AFFORD THIS KIND OF CARE. AFTER SIX MONTHS IN THE HOSPITAL, HART WENT HOME ON A VENTILATOR. BUT HIS MEDICAL NEEDS DIDN’T STOP THERE. TO STAY ALIVE, HE NEEDED HOME NURSING TWENTY-FOUR HOURS A DAY. HIS HMO, HUMANA, PICKED UP THE BILL.

b-roll: Nurses in McConnell home with Hart

MIKE MCCONNELL: They were providing nursing, twenty-four hour a day nursing, They were providing the durable medical equipment. All the machines...

nat sound:

CRISS MCCONNELL: This is a bi-level continuous airway pressure machine.

MIKE MCCONNELL (o/c): . . . the oxygen, the tubing. Medications that he required. Hart was so critical, that if they denied anything, he could die.

DR. TONY KRISEMAN (o/c): You’ve come home with the expectation of having a normal child and you’re faced with a very abnormal child who is going to be consuming your every waking and sleeping moment.

NARR: DR. TONY KRISEMAN IS HART’S PEDIATRIC PULMONOLOGIST.

Dr Tony KrisemanDR. KRISEMAN: To have a child in your home that has a chronic illness is burdensome enough in terms of family stresses and strains. To have a child that has a chronic illness that requires technology to maintain them alive, multiplies those stresses and strains a hundred fold.

CRISS MCCONNELL: You are never ever, ever off and your child’s life depends on how well you’re on and how well you can perform.

b-roll: nurses in McConnell home with Hart

NARR: AFTER ALMOST TWO YEARS OF ROUND-THE-CLOCK CARE COSTING CLOSE TO TWO MILLION DOLLARS, PAID BY HUMANA, HART MCCONNELL NO LONGER NEEDED TO BE HOOKED UP TO A VENTILATOR FULL TIME. THOUGH HE CONTINUED TO REQUIRE SOME OXYGEN THROUGH HIS TRACH TUBE. AS HART’S MEDICAL CONDITION IMPROVED, THE FAMILY’S INSURANCE SITUATION TOOK A TURN FOR THE WORSE.

KRISTIE SIMPSON (v/o): They saw that Hart was on the ventilator less and less at night.

NARR: KRISTIE SIMPSON WAS DIRECTOR OF NURSING FOR THE HOME HEALTH COMPANY USED BY THE MCCONNELL’S HMO, HUMANA.

SIMPSON (o/c): Well they see this improving and they’re going ‘cut his nursing hours. We need to cut his nursing hours. He’s not on the ventilator any more.’

SMITH: So what was your reaction?

b-roll: Criss McConnell caring for Hart

SIMPSON: I was very outraged and I explained the first two months after a trach is taken out and a child is breathing by themselves, is the most crucial and serious time.

nat sound: Hart coughs

CRISS MCCCONNELL (v/o): I know that that’s a very potentially dangerous time, that’s a time that that child has to be monitored very, very, very closely.

NARR: OVERWHELMED BY THE GROWING CARE BURDEN FOR HART, THE MCCONNELLS TURNED TO DR. KRISEMAN. HE AND HART’S PEDIATRICIAN WROTE PRESCRIPTIONS TO MAINTAIN 16 HOURS OF HOME NURSING.

DR. KRISEMAN (o/c): He’s made significant gains but he’s still a fragile child.

NARR: ...BUT EVEN THAT DIDN’T WORK.

MIKE MCCONNELL: Within 48 hours a denial of services arrived at our door. A written denial of services.

SMITH: Cut you to zero?

MIKE MCCONNELL: Well, yes I didn’t know that at the time. I looked at it and I called the case manager. And I asked her, I said, does this mean that you’re denying the additional hours back to 16 hours? She said no. It means we’re denying all nursing. You’re cut off. I said, ‘Well you can’t do that.’ ‘Well, you know,’ she said, ‘I have no control over that.’

b-roll: Hart on breathing apparatus, etc.

NARR: CRISS, WHO ALREADY QUIT HER JOB TO HELP THE NURSES, WAS FORCED TO TAKE OVER ALL OF HART’S CARE.

CRISS MCCONNELL (v/o): I was beyond terrified. Have you ever been so scared that you can’t like, feel your fingers? You’re just paralyzed with fear? ...Would I be smart enough? Would I be gutsy enough? What if he pulled out the tube in his neck?

NARR: ... EACH MORNING, SHE REMOVES THE APPARATUS THAT HELPED HIM BREATHE ALL NIGHT LONG....

NARR: THEN SHE CHANGES THE GASTRIC TUBE THAT FEEDS HART THROUGH A HOLE IN HIS BELLY….

nat sound: Hart crying

Chris McConnell: "I’m sorry, Sweet Guy. I’m sorry."

NARR: SOMETIMES IT GETS STUCK AND PULLING IT OUT IS PAINFUL….

nat sound/b-roll: Criss McConnell feeding Hart

Criss Mcconnell: Goat milk and chicken and some liver and spinach, kale, sweet potatoes, carrots, yogurt. . .

NARR: THIS IS HART’S ONLY WAY TO GET NOURISHMENT… FOUR TIMES A DAY, HE GETS FED THIS WAY.

nat sound:

Criss McConnell: All mixed up in this delightful . . .

CRISS MCCONNELL: It’s just constant, constant on, on, on 24 hours a day, day after day after day after day.

NARR: MANY OTHER FAMILIES HAD SIMILAR CUTOFFS FROM OTHER HMOS, ACCORDING TO KRISTIE SIMPSON, WHO WORKED WITH SEVERAL MANAGED CARE PLANS.

KRISTIE SIMPSON: They would say, no, Kristie, insurance is only responsible for so many things. If it’s a skill the parent can learn - that was what I heard all the time from Humana, all the other big companies - if it’s a skill the parent can learn, then they do not need nursing hours for that. They have their guidelines that are unrealistic.

SMITH: What’s the problem here?

DR. KRISEMAN: The problem is that there’s a, an adversarial relationship between virtually all HMOs and medical care teams and patients.

DR. KRISEMAN: And it’s a conflict of interest the way insurance works at this time. The HMO’s goal is to spend as little money to keep patients in reasonable health as possible and if that tramples on medical decision making so be it from their perspective. Our goal is to do the best for our patients.

NARR: HUMANA’S DR. JERRY REEVES, THEN SENIOR VICE PRESIDENT AND CHIEF MEDICAL OFFICER, ACKNOWLEDGED THE CONFLICT.

DR. JERRY REEVES: The way our American health insurance is put together by design creates conflict. So we are experiencing a lot of that conflict personally.

SMITH: How do you determine medical necessity. The kid looks as though he’s in the same shape as he was in . . . you know, just weeks before?

DR. REEVES: Not everything that is medically necessary is covered by the insurance plan. That, that’s a fact of life that we all have to get accustomed to.

b-roll of Hart McConnell:

NARR: THE FACT IS COMMERCIAL INSURERS LIKE HUMANA MAKE A PROFIT WHEN MEMBERS STAY HEALTHY, BUT LOSE MONEY WHEN PATIENTS NEED A LOT OF CARE, SAYS HEALTH ECONOMIST HAL LUFT.

b-roll: Patients in hospital

HAL LUFT: We pay them a fixed amount and then we hold them responsible for taking care of all the needs of those people, and people who will require a lot of medical care will be very expensive. It’s sort of like the smorgasbord restaurant, that probably doesn’t want to invite people who are very overweight, uh, because they’re saying $5, all you can eat, and they’ll lose money pretty quickly.

nat sound: Blips from hospital equipment

LUFT (v/o): If you enroll a lot of people who are very high cost, you can end up spending more than what you bring in, in premium, and you won’t be able to stay in business very long.

DR. REEVES (o/c): Investors want a profit. And whether it’s for profit or not for profit, you still have to have something left over at the end of the year to still be here next year.

b-roll: Criss helping Hart use nebulizer

NARR: THE McCONNELLS SOLVED THEIR CARE CRISIS BY TURNING TO FLORIDA’S PROGRAM FOR MEDICALLY NEEDY CHILDREN, WHICH AGREED TO PAY FOR 16 HOURS A DAY OF HOME NURSING. HUMANA LATER OFFERED 8 HOURS, BUT BY THEN, HUMANA’S OFFER WAS TOO LITTLE, TOO LATE.

b-roll: McConnell family at Disney World

Montage With HeartMIKE MCCONNELL: If you’ll get in their face and punch hard enough then you can make out OK. But if you don’t have the emotional or physical strength or wherewithal to do that they’ll grind you to dust.

montage and music bridge

b-roll: Hospital patients, health care company exteriors, stock market

NARR: FOR THE AVERAGE FAMILY, A CHRONIC ILLNESS WOULD BREAK THE BANK. SO LIKE THE McCONNELLS, MOST AMERICANS RELY ON INSURERS LIKE HUMANA, CIGNA, AND AETNA-US HEALTHCARE FOR COVERAGE. BUT THESE FOR-PROFIT COMPANIES ARE IN BUSINESS TO MAKE MONEY AND SO THEY WORK HARD TO LOWER COSTS. AND THAT CREATES TENSION. BECAUSE HEALTHCARE IS ABOUT SAVING LIVES...AND CARING FOR THE SICKEST PEOPLE WITH THE LATEST TECHNOLOGY, INEVITABLY PUSHES UP COSTS.

nat sound/b-roll: MRI suite

Technician: "Ok. We’re about to start taking your pictures. Make sure to hold your head nice and still for me."

CATHERINE HOFFMAN: Life expectancy in the last century improved by 25-30 years. But the side effect of that has been that many more of us live with chronic conditions. And our health care system hasn’t caught up with what the needs of those people are.

NARR: CATHERINE HOFFMAN, A LONG-TIME CARDIAC CARE NURSE, IS NOW A HEALTH SERVICES RESEARCHER WHO STUDIES THE CHRONICALLY ILL.

b-roll of Hart McConnell and family at Disney World

HOFFMAN (v/o): By definition, chronic conditions are those that can’t be cured. The goal really needs to be how can we maximize what they can do on a day to day basis and live the fullest lives that they want to live. And that takes a whole different approach than the system provides right now.

NARR: MANAGING AND PAYING FOR CHRONIC CONDITIONS POSES A HUGE CHALLENGE FOR INSURERS LIKE HUMANA.

DR. REEVES (o/c): We find that among our members, there are about 30 conditions that are the core contributors to these high costs and this high burden of illness. One chronic disease doubles the amount of medical cost per year. Two chronic diseases in the same patient triples their medical cost per year.

NARR: HUMANA, BASED IN LOUISVILLE KENTUCKY, HAS SIX MILLION MEMBERS, AND FLORIDA IS ITS PRIME MARKET.

nat sound/b-roll: Humana service representatives:

Humana Service Rep: Thank you for calling Humana. This is Kathy. May I have the member’s ID number please?

NARR: WHEN SELLING HEALTH INSURANCE PLANS, HUMANA ASSUMES A RISK. IN EXCHANGE FOR A MONTHLY PREMIUM, HUMANA PROMISES TO TAKE CARE OF PATIENTS IN SICKNESS AND IN HEALTH.

nat sound:

Humana Claims Operator: . . . And the $470 for the doctor bill . . .

NARR: WITH 10% OF HUMANA’S SICKEST PATIENTS ACCOUNTING FOR 80% OF THE COMPANY’S MEDICAL BILLS, HUMANA TURNED TO A STRATEGY CALLED DISEASE MANAGEMENT TO HANDLE SEVERAL CATEGORIES OF CHRONIC PATIENTS….ESTIMATING THAT IT WOULD SAVE AS MUCH AS SEVENTY-EIGHT MILLION DOLLARS.

DR. REEVES: At Humana, we believe that disease management is really the engagement of care support teams to improve health for members. We are trying to organize care and/or coordinate care and work within a budget.

nat sound:

Service Rep: Thank you.

DR. RICHARD VANCE: Targeting those patients proactively you can prevent a catastrophic event like a myocardial infraction - or heart attack - or stroke or uh, um, an exacerbation of congestive heart failure.

b-roll: Hospital patients

NARR: AND CONGESTIVE HEART PATIENTS ARE ONE OF THE MOST COSTLY GROUPS FOR HUMANA.

DR. REEVES: They find if they just try to walk across the room or walk to the car they get short of breath because their heart pump is pumping so poorly. Now they didn’t want to bother the doctor so they would just go to the emergency room once they were just so uncomfortable they couldn’t cope and end up being in the intensive care unit.

NARR: NATIONWIDE, CONGESTIVE HEART FAILURE ACCOUNTS FOR OVER SEVENTEEN BILLION DOLLARS IN HEALTH CARE SPENDING EACH YEAR. IT’S THE MOST COMMON HOSPITAL DIAGNOSIS FOR MEDICARE PATIENTS … PEOPLE LIKE HUMANA MEDICARE HMO MEMBER JEANNE LANGE, A RETIRED SCHOOLTEACHER.

nat sound:

Pam Robinson: Good Morning, Mrs. Lange? This is Pam Robinson . . .

NARR: TO MANAGE HER CARE AND OTHERS LIKE HER, HUMANA HAS FOUND AN INEXPENSIVE SOLUTION TO THOSE EMERGENCY ROOM VISITS...

nat sound:

CorSolutions Receptionist: CorSolutions, formally Cardiac Solutions . . .

Disease manager/nurse #1: Did he make any changes on any of your medicine or . . . ?

NARR: USING TELEPHONE CONTACT BY NURSES . . .

nat sound:

Nurse #2: I need to check your medications.

NARR: CORSOLUTIONS HELPS MONITOR AND ADVISE HUMANA’S HIGHEST RISK HEART FAILURE PATIENTS.

nat sound:

Nurse #3: 20 milligrams a day.

NARR: . . . TO AVOID COSTLY COMPLICATIONS AND HOSPITAL STAYS.

nat sound:

Nurse #4: So I hope that you get the book the next time I speak to you because then we can go over the information in the book.

Robinson: Remember now, the pies and the pastries…

PAM ROBINSON: A lot of them think of me as their friend calling.

NARR: PAM ROBINSON, JEANNE’S DISEASE MANAGER, CALLS HER REGULARLY...

Nat Sound:

Robinson: How are you doing today?

NARR: . . . TO KEEP JEANNE HEALTHY AND ON TRACK.

nat sound:

Robinson: Have you gone out to eat at all, in the last week or two?

NARR: ADHERING TO A LOW SODIUM DIET

nat sound:

Pam Robinson: That’s good. The baked potato is a good choice. And the salad is a good choice.

NARR: …AND TAKING THE RIGHT MEDICATIONS.

Robinson: "Mmm. Okay. How’s your weight been doing? 170? Great. I’m going to go through some of the heart failure questions with you right now. How’s your energy level been? Any lack of energy interfering with your activities? Uh-huh . . ."

NARR: EVEN THOUGH THE PROGRAM IS DESIGNED TO PREVENT EMERGENCY ADMISSIONS, THE NURSES ENCOURAGE PATIENTS TO SEEK MEDICAL CARE BEFORE A CRISIS ERUPTS.

ROBINSON: She didn’t want to go to the doctor cause she didn’t want to be put in the hospital . . .

LANGE: I finally did go to the doctor and, and I was put in the hospital for a short time.

nat sound/b-roll: Jeanne Lange

NARR: JEANNE HAD A SHORT HOSPITAL STAY, BUT IT COULD HAVE BEEN LONGER HAD IT NOT BEEN FOR PAM’S INTERVENTION. THAT HELPS HUMANA’S BOTTOM LINE.

DR. JERRY REEVES: There are 60% lower total hospital costs and emergency visits compared to those that are not receiving the program, you know, before they were enrolled.

b-roll: Jeanne Lange with family, shopping, eating

NARR: NORMALLY, ONE IN FIVE CONGESTIVE HEART FAILURE PATIENTS DIES WITHIN A YEAR OF DIAGNOSIS. WITH COR-SOLUTIONS, HUMANA HAS CUT THEIR MORTALITY RATE IN HALF — TO ONE IN TEN.

nat sound:

Jeanne Lange: It’s good for you. It’s got cauliflower . . .

Jenane With The FamilyNARR: FOR JEANNE LANGE, THAT TRANSLATES INTO MORE TIME WITH HER DAUGHTER AND GRANDDAUGHTER.

nat sound: Jean and family

DR. REEVES (v/o): The dividends are a patient that is not so sick. If we can make these people well, and they don’t need as much services, they are happy and we are happy.

CATHERINE HOFFMAN (o/c): And if you’re lucky enough to have that kind of disease where the disease management program has been set up, then you get a real good taste of how good health care could be for you in America.

b-roll: chronic patients receiving treatment

NARR: BUT FEW CHRONIC ILLNESSES PAY OFF SO QUICKLY THROUGH DISEASE MANAGEMENT, SAYS DR. TOM BODENHEIMER, A PRACTICING PHYSICIAN AND CLINICAL PROFESSOR.

DR. TOM BODENHEIMER: If you have an organization that is worried about Wall Street and the stock market, they are only going to take care of chronic disease if that saves them money, and most chronic disease programs don’t save money maybe until five to ten years in the future.

NARR: SO TO MANAGE ITS RESOURCES, HUMANA HAS TO MAKE CHOICES.

DR. REEVES: We try to deploy the resources that we have within the budget constraints as best we can to improve the health of our members. And we cannot do all things for all people.

b-roll & nat sound Caitlyn Chipps:

Caitlyn Chipps: "How does my hair look?"

NARR: BUT DOES THAT MEAN THAT JEANNE LANGE’S HEART PROGRAM CAME AT A COST OF CARE FOR OTHERS? MARK CHIPPS SAYS IT DID.

NARR: CHIPPS’ DAUGHTER, CAITLYN, HAS BEEN STRICKEN WITH CEREBRAL PALSY SINCE BIRTH. SHE NEEDS ACCESS TO SPECIALISTS, INTENSIVE THERAPIES, AND CUSTOMIZED FOOT BRACES IN ORDER TO FUNCTION INDEPENDENTLY.

nat sound/b-roll: Mark Chipps with dog

NARR: CHIPPS ENROLLED HIS FAMILY IN A HUMANA HEALTH PLAN IN 1994 THROUGH HIS EMPLOYER, THE PALM BEACH COUNTY SHERIFF’S OFFICE, AND WAS PROMISED ENROLLMENT IN A SPECIAL PROGRAM WITH EXTENDED BENEFITS FOR CAITLYN.

b-roll: Barbara Chipps putting Caitlyn’s braces on her

NARR: FOR NEARLY TWO YEARS CAITLYN CHIPPS RECEIVED THERAPY THROUGH HUMANA, UNTIL DECEMBER 1995 WHEN HER REHABILITATION CENTER ADMINISTRATOR DELIVERED SOME BAD NEWS.

MARK CHIPPS: She said, ‘I was just faxed a letter from Humana stating that they were taking your daughter off of case management and that they were no longer going to pay for her therapies.’ And I couldn’t believe it.

b-roll: Mark Chipps helping Caitlyn into care

NARR: CAITLYN STILL HAD INSURANCE, BUT LOST THE EXTENDED BENEFITS COVERING HER SPECIAL THERAPIES. MARK, AND HIS WIFE, A BANK TELLER, WOULD HAVE TO PAY FOR THOSE TREATMENTS ON THEIR OWN.

CHIPPS: It was about $18,000 a year of treatment that she needed. Um you know, at that point, we were talking about second mortgages.

NARR: STRAPPED FINANCIALLY, THE CHIPPS HAD TO REDUCE HER THERAPY.

b-roll: Caitlyn

CHIPPS (v/o): 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. We noticed her starting to crawl a lot more.

b-roll: Mark Chipps enters courthouse

NARR: FRUSTATED BY REPEATED FAILURES TO GET HUMANA TO PAY FOR HIS DAUGHTER’S TREATMENT, CHIPPS DECIDED TO TAKE LEGAL ACTION. AFTER HIS ATTORNEY, TED LEOPOLD, FILED SUIT AGAINST HUMANA, HE MADE A STARTLING DISCOVERY.

TED LEOPOLD (o/c): What happened to Caitlyn happened to dozens of other catastrophically ill children.

CHIPPS: There was a, uh, a case manager who was in charge of a market here in Florida and she was told by, uh, corporate office in Louisville that they were going to initiate these other programs and in order to be cost effective, and have the personnel to monitor these other programs, they had to weed out the pediatric patients in case management.

NARR: THAT HUMANA CASE MANAGER, JUNE BRIGHTON, TESTIFIED IN A VIDEO DEPOSITION THAT SHE HAD ELIMINATED 14 CHILDREN FROM THIS SPECIAL PROGRAM.

video deposition:

JUNE BRIGHTON: Well, my, my understanding was that I needed to weed them out - those that were stable - and close them - those that could be handled by the primary care doctor.

LEOPOLD (OFF CAMERA) "Weed them out," you’re referring to the catastrophically ill children?

BRIGHTON: Well, the ones that were considered stable at the that time, yes.

LEOPOLD (OFF CAMERA): Those, those pediatric patients that were in the medical case management program that you were overseeing?

BRIGHTON: Right. Right.

SMITH: What was your reaction when you heard that?

MARK CHIPPS: I was furious. How dare they. How dare they do this to these kids. Teh! Still pretty angry.

NARR: I ASKED DR. REEVES WHY, ACCORDING TO HUMANA’S COURT TESTIMONY, HUMANA ELIMINATED DOZENS OF CHRONICALLY ILL CHILDREN FROM CASE MANAGEMENT?

SMITH: Why would that happen?

DR. REEVES: I really can’t venture a guess not being there in that particular setting. There are a lot of factors that go into enrollment or non-enrollment in case management. The way we design our case management programs are to have entry criteria. That is we have a reason to believe they would benefit from these interventions. And exit criteria. That is we believe that they have achieved the majority of the benefits they can gain.

LEOPOLD: Humana had very specific guidelines to keep these children in the medical case management programs. The guidelines, the policies and procedures were not followed. They weren’t even reviewed.

NARR: DR. LINDA PEENO, A FORMER MANAGED CARE EXECUTIVE NOW TEACHING AT MEDICAL SCHOOL, TESTIFIED IN THE CHIPPS CASE AS AN EXPERT WITNESS.

DR. LINDA PEENO: Well, when you get certain categories of patients who have chronic, sort of static chronic needs, where all you’re doing is paying money. You’ve already negotiated the lowest rate for speech therapy. You’ve already negotiated the lowest rates for durable medical equipment. You can’t squeeze out any more savings. Then those persons become just a drain, just a financial hole.

DR. REEVES: As a pediatrician, I see children that have things that they could be helped with additional services that would be awful nice to have. The question is whether those take priority over those where someone is going to be admitted to an intensive care unit or they’re- they have another heavier burden of illness.

CHIPPS: But you can’t, you can’t get rid of these kids and just weed them out so that you save money by getting these kids out of the program, denying their claims and at the same time centering all your attention on these other folks so it’s a save save for Humana.

SMITH: So it’s money?

CHIPPS: It’s money. It’s money. It’s cost over care. Cost over care.

nat sound:

Humana service rep: Thank you for calling Humana. This is . . .

NARR: HUMANA DENIED THAT IT WAS CUTTING OUT CHILDREN TO SPEND ITS MONEY ON OTHER PROGRAMS, SUCH AS CONGESTIVE HEART FAILURE.

Dr Richard VanceDR. RICHARD VANCE: This is not merely an issue of picking elderly patients over young patients. My understanding is that there was no linkage between those two and it makes no sense that there would be any linkage between the two.

NARR: BUT MARK CHIPPS DISAGREED. A PALM BEACH JURY AWARDED HIM AND HIS FAMILY A RECORD VERDICT AGAINST HUMANA...

b-roll: Local news footage/Nat Sound:

Juror: What is the total amount of punitive damages to be assessed against defendant, Humana Health Insurance Company: 78 million five hundred thousand dollars. So say we. . .

NARR: IRONICALLY, THAT WAS ALMOST EXACTLY THE AMOUNT THAT HUMANA FIGURED IT WOULD SAVE FROM ITS DISEASE MANAGEMENT PROGRAMS.

DR. REEVES: Do I wish that she had received all of the services? Do I wish that every child would receive all the services that they might be benefited by? Yes. Do we have the resources nationally to provide everything that’s beneficial for every person? We can no more do that than we can provide everything that might be beneficial for every child receiving an education.

b-roll/nat sound Caitlyn & Mark Chipps — getting her out of the car, walking into school

DR. PEENO: I think the Chipps case is probably one of the most important cases for us to understand as the American public. Essentially, you know, managed care is a model that is based on limitation and denial of care in order to save money. And you can see in the Chipps case, the very sophisticated methods that have emerged to do that.

stroke montage bridge:

nat sound: sirens/stroke patients.

Marijane Schacherer: My head was mushy, my speech was slurred.

Sarah Oczkowski: And I could see he was having trouble.

Anthony Oczkowski: And I fell on the floor in the, in the living room there; I couldn’t get up.

Sarah Oczkowski: I ran out and got him. We gotta call. 911.

Marijane Schacherer: And it was very scary. Could this be a stroke?

Marijane Schacherer: I don’t want to have another one.

NARR: AFTER A STROKE, LIFE AS YOU KNOW IT COMES TO AN END. THE ROAD HOME, FOR THE LUCKY ONES, IS LONG AND EXPENSIVE.

b-roll: therapy/nat sound:

Physical therapist: Left foot, right foot.

NARR: -- FILLED WITH HOURS OF THERAPY… STRUGGLING IN SOME CASES TO REGAIN EVEN THE MOST BASIC FUNCTIONS. GETTING HOME AND BEING INDEPENDENT IS THE GOAL. WHAT IS CRITICAL IS THE QUALITY OF REHABILITATION YOU GET RIGHT AFTER YOUR STROKE.

MARIJANE SCHACHERER (v/o): I suppose I would have gone into a nursing home or something.

NARR: INSTEAD, MARIJANE SCHACHERER’S DOCTOR, FACED WITH HER PARALYZING DISABILITIES, PRESCRIBED ACUTE INPATIENT REHABILITATION AT LEE MEMORIAL HOSPITAL IN FORT MYERS, FLORIDA.

SCHACHERER (o/c): He said, you know, ‘Get right over to Lee Memorial Rehab.’

b-roll: Sarah Oczkowski helping Anthony use walker

NARR: LIKE MARIJANE, ANTHONY OCZKOWSKI, A RETIRED SCHOOL TEACHER ALSO LIVING IN FORT MYERS, SUFFERED A STROKE. BUT HIS ROAD TO RECOVERY TOOK A VERY DIFFERENT PATH.

ANTHONY OCZKOWSKI: They were fighting among themselves of where to take me next. And she’ll tell you the story.

SARAH OCZKOWSKI: The doctor, his doctor, Dr. Bonnette, he’s the stroke specialist. He said that acute care at Lee Memorial was the best for him because, uh, he would convalesce much quicker. And I was very upset about that because Humana wouldn’t agree to it.

nat sound: car running/b-roll: Anthony with walker going from house to car

SARAH OCZKOWSKI: They had me crying on the phone. I said my doctor recommends something and you won’t follow through with it.

b-roll: Dr. Bonnette at review meeting

NARR: ANTHONY’S NEUROLOGIST, DR. HARRIS BONNETTE, IS A HUMANA DOCTOR AND A DIRECTOR OF LEE MEMORIAL’S SKILLED NURSING FACILITY AND ITS REHABILITATION HOSPITAL:

DR. HARRIS BONNETTE: On a daily basis we review ten to twenty odd patients.

NARR: NOT EVERYONE QUALIFIES FOR ACUTE REHABILITATION...

BONNETTE REFERS PATIENTS TO THE TYPE OF FACILITY THAT BEST MEETS THEIR NEEDS.

DR. BONNETTE (v/o): We make this decision based on clinical information, not financial.

SMITH: Why did your husband’s doctor recommend the Lee Hospital? Did he say it was better?

SARAH OCZKOWSKI: Because he would get acute care.

NARR: COLEEN BRONSON, A FORMER REHABILITATION NURSE, WAS MR. OSCKOWSKI’S CASE MANAGER IN THE HOSPITAL.

SMITH: Do you think that most patients and their families understand the difference between getting care at what you call an acute rehabilitation facility and a sub-acute nursing home facility.

COLEEN BRONSON: Patients and their families absolutely do not understand the difference between the two facilities…. I usually explain that to patients who have a choice. Not all patients have that choice because the insurance will sometimes dictate, and those patients I don’t explain the differences to because I want them to think they are getting the best.

NARR: DR. ANDY KRAMER, AT THE UNIVERSITY OF COLORADO CENTER ON AGING, HAS DONE NATIONAL STUDIES ON STROKE...COMPARING TREATMENT WITH OUTCOMES.

b-roll: Stroke therapy

DR. ANDY KRAMER (v/o): If you look at the inpatient rehabilitation centers as we did and compare them to nursing homes. There is twice as much therapy, there is twice as much physician care, there is three times as much specialty physician care like neurologists and physical medicine doctors. So it’s a much more intense environment for rehabilitation.

b-roll: Marijane getting therapy

SCHACHERER: You are up at, you know, 6:30 in the morning and you’ve got a schedule that’s just like you were working….

DR. KRAMER: ...And as a result, they have a much better improvement rate."

nat sound:

Occupational Therapist: That was nice, Marijane.

Marijane with DoctorClose up Marijane’s hands shot at end of interview as inserts

SCHACHERER (o/c): I’m telling you everyday there is some progress. I had a small tube of sample size tube of toothpaste. Went to put it in this hand and this hand couldn’t hold it. Sunk right down on the, on the bathroom sink. About two days later, I put the little tube of toothpaste in there and this hand could hold it. So I thought well, I’ll be darned. About two days after that, I could press a little toothpaste out onto my brush….And that, to me, is progress.

NARR: ANTHONY’S HMO, HUMANA, SENT HIM TO A NURSING HOME, OVERRULING HIS DOCTOR.

Nat sound:

Coleen Bronson: And the patient should be able to go to rehabilitation . . .

b-roll: nursing home

NARR: COLEEN BRONSON SAYS THIS APPROACH IS COMMON AMONG HMOS. SHE AND DR. BONNETTE APPEALED TO HUMANA TO KEEP ANTHONY OUT OF A NURSING HOME.

BRONSON: We tell you that it’s time to get on with rehabilitation and then you come through the doors of this facility and what you see is that you’ve entered a nursing home. And I think that that takes the wind out of some people's sails.

SARAH OCZKOWSKI: He didn’t like the environment there because it depressed him.

ANTHONY OCZKOWSKI: And I said, "This is not for me." So I get out there and I do the exercises as quickly and proficiently as possible - just to prove that you’ve got the wrong guy. I shouldn’t be in here.

SMITH: What did you see when you visited the nursing facility?

SARAH OCZKOWSKI: They were concentrating his therapy in the morning. I asked the charge nurse why he wasn’t getting therapy in the afternoon and she says, ‘Oh well you can take him over there.’ But we waited a couple of days and there wasn’t, you know, he hadn’t gone at all. So after that, I pushed it.

b-roll: stroke therapy

NARR: PROVIDING REHABILITATION IN A NURSING HOME IS A GREAT COST SAVER TO HEALTH PLANS. IT CAN CUT AS MUCH AS HALF THE COST PER DAY.

SMITH: What was Humana’s rationale for denying Mr. Oczkowski access to an acute rehabilitation center?

BRONSON: They said that he could get his needs met at the nursing home setting and that because of that they were going to choose the less costly option.

DR. JERRRY REEVES: The focus of what we are trying to do is to organize care so that you achieve the end results. It doesn’t necessarily take, you know, a facility of type X to achieve those results as fast. It’s where can we get the results that we are, are aiming for. That is improved function of the stroke patient.

SMITH: Here is the situation where a man is in a hospital. He has a stroke and his doctor, his doctor who’s a specialist, who’s a neurologist recommends an acute rehabilitation center. But the HMO says no. Now there is medical advice. What’s going on?

DR. KRAMER: Yeah. It’s, what’s going on in that situation is that the HMO only has contracts and services set up to provide nursing home level rehabilitation and does not authorize it for inpatient rehabilitation.

SMITH: Well, what you’re saying is that if HMO’s are contracting for bulk medical care, for hundreds and thousands of people, it may not serve the individual very well.

DR. KRAMER: I think that’s one of the problems in trying to manage care for specific conditions, in the context of a very, uh, broad population with a whole array of problems, yes.

NARR: I ASKED DR. RICHARD VANCE, HUMANA’S VICE PRESIDENT FOR HEALTH IMPROVEMENT, WHETHER HUMANA WOULD EXAMINE STROKE REHABILITATION IN LIGHT OF DR. KRAMER’S RESEARCH.

DR. RICHARD VANCE: I already know the studies that are there. If I find that, in fact, appropriate services are not being provided for patients where they need those in order to achieve optimal recovery, yes, I want that fixed.

b-roll: stroke therapy in nursing home and acute rehabilitation center

NARR: ANDY KRAMER HAS DONE TWO STUDIES. ONE COMPARES TRADITIONAL MEDICARE, WHICH USUALLY PAYS FOR ACUTE REHABILITATION, AND HMOS, WHICH GENERALLY SEND STROKE PATIENTS TO NURSING HOMES.

DR. KRAMER: To give you a sense of the magnitude of the issue: If you’re in traditional Medicare, you are twice as likely to be in your home a year after your stroke than if you were in an HMO.

NARR: MARIJANE WHO GOT THE BENEFIT OF ACUTE REHABILITATION, IS HOME, LIVING INDEPENDENTLY, 12 WEEKS AFTER HER DEVASTATING STROKE.

b-roll/nat sound: Marijane brushing teeth, grocery shopping, etc.

SCHACHERER: Well, I never thought I’d be walking this fast with just a cane and I really walk without the cane, so from bed to, uh, you know, walking around a bit, I’ve come a long way.

b-Roll Schacherer in the grocery store/b-roll: Sarah helping Anthony

NARR: WORRYING ABOUT SPECIALTY CARE IS OFTEN THE LAST THING ON PEOPLE’S MINDS WHEN THEY ARE SHOPPING FOR A HEALTH PLAN.

SARAH OCZKOWSKI: $10 for the doctor, $15 for a specialist . . .

ANTHONY OCZKOWSKI: And then your cost of medicine is reduced to $5 a throw...

SARAH OCZKOWSKI: Yeah.

PATRICIA GOLDSMITH: The typical consumer tends to choose their health plan based upon looking at a directory that says your office co-payment is $10, your coverage for prescriptions is $10 per month per prescription.

NARR: PATRICIA GOLDSMITH IS A VICE PRESIDENT AT TAMPA’S

H. LEE MOFFITT CANCER CENTER, IN CHARGE OF MANAGED CARE.

GOLDSMITH (v/o): They look at the book and they see that their physician that they may have gone to a few times is in the book and they determine that it’s a very good plan. And on the surface it probably is. The problem is, most individuals do not think beyond that immediate need for routine medical care.

b-roll: examining mammograms

PATRICIA GOLDSMITH (v/o): With one out of three Americans being diagnosed with cancer at some point in their lifetime, you have to look beyond the basics.

Valerie Kennedy with IVVALERIE KENNEDY (o/c): I was a runner. I didn’t eat meat. I was a vegetarian. I took vitamins. I didn’t have a family history. And none of that mattered. Not one bit.

NARR: SO VALERIE KENNEDY, AT 37, WAS COMPLETELY UNPREPARED TO FIND A CANCEROUS LUMP IN HER RIGHT BREAST DURING A MONTHLY SELF EXAM. AS A HUMANA EMPLOYEE, SHE GOT HER HEALTH PLAN FROM HUMANA, AND WENT TO SEE ONE OF THE PLAN’S SURGEONS.

KENNEDY: The first doctor said gee, you, you should have a mastectomy. And you know, while you’re at it, you should have a double mastectomy. Well you know, I was 37 years old. And I didn’t, you know, thought I need to know all the facts before I go do something like this.

NARR: A SINGLE PROFESSIONAL WHO HOPED ONE DAY TO MARRY AND START A FAMILY, VALERIE WANTED THE VERY BEST CANCER CARE AVAILABLE IN HER HOMETOWN OF TAMPA.

nat sound/b-roll: Valerie & her sister

KENNEDY (v/o): I wanted to go someplace that I felt like was state of the art, where people were on top of all the latest procedures and technologies. It was my life, I wasn’t playing around with that.

NARR: HER RESEARCH LED HER TO MOFFITT, FLORIDA’S ONLY NATIONAL CANCER INSTITUTE DESIGNATED CANCER CENTER.

KENNEDY: I knew it had a great reputation. You know, you couldn’t live in that area and not know about them. They were highly respected.

nat sound:

Dr. Charles Cox: and we’ll also get the mammogram, the digital hopefully and the regular mammo…

b-roll: Moffitt infusion center

KENNEDY (v/o): You know, you walk in there and there are a lot of sick people there. It’s a it’s a serious place and I would look around, especially on that first visit, when I went into the breast clinic and there were you know women sitting out there with no hair. And I remember thinking, ‘Oh, God. This is my future.’ I wanted to turn and run but I knew I couldn’t.

NARR: VALERIE WAS TREATED FOR HER STAGE TWO CANCER AT MOFFITT, BY BREAST CANCER SPECIALIST DR. CHARLES COX.

Nat sound/b-roll: Valerie Kennedy and Dr. Cox:

Dr. Cox: You probably want to do a digital mammogram, which is the new type of mammogram…

Medical Training Video

NARR: UNDER HIS CARE, SHE UNDERWENT TWO LUMPECTOMIES AND LYMPHATIC MAPPING, AN ADVANCED PROCEDURE THAT MOFFITT HELPED TO PIONEER. IT DETERMINES HOW FAR CANCER HAS SPREAD INTO SURROUNDING LYMPH NODES.

Humana Public Service Announcement:

Kennedy: Six months ago I started surgery, chemotherapy and radiation for a disease that is killing a woman every 12 minutes, seven days a week, 24 hours a day: Breast Cancer. My first thought was, you know, oh god, am I going to die?

NARR: IN THIS PUBLIC SERVICE ANNOUNCEMENT FOR HUMANA, VALERIE TALKED CANDIDLY ABOUT HER CANCER AND THE NEED FOR PREVENTIVE CARE.

PSA: I know the importance of a monthly self examination. It saved my life. Now it might save yours too.

SMITH: And how much did it cost you?

VALERIE KENNEDY: In dollars? Nothing. Uh, I might have paid a deductible. But that was about it. I mean that’s what I, when I say I was lucky. I really was. I had great care, um, and I didn’t, the, the monetary cost was minimal to me.

nat sound:

Kennedy: Singing to Brendan " You are my sunshine, my only sunshine."

NARR: SINCE HER TREATMENT AT MOFFITT, VALERIE KENNEDY HAS MARRIED, MOVED TO CHICAGO, AND GIVEN BIRTH TO HER FIRST CHILD. CANCER-FREE FOR TWO YEARS, SHE STILL RETURNS TO MOFFITT FOR A CHECK-UP.

 

nat sound/b-roll: Valerie and family at Moffitt:

Nurse: I want to see that little guy . . .

Valerie: Yeah, look at him.

NARR: AND A CHANCE TO INTRODUCE HER HUSBAND AND NEWBORN SON…

nat sound:

Valerie: Isn’t he the cutest?

NARR: ….TO THE PEOPLE WHO SAVED HER LIFE.

nat sound:

Valerie: April, this is my husband Mark.

Mark Traverso: Hi.

April: Hi.

KENNEDY: They gave me back my life. And I’m a very lucky woman.

NARR: THAT’S THE KIND OF HAPPY ENDING MOST CANCER PATIENTS HOPE FOR — GREAT CARE, AT MINIMAL COST, AND LIFE GOES BACK TO NORMAL. … VALERIE KENNEDY WAS FORTUNATE…

STANDUP: BUT HER EXPERIENCE WAS AN EXCEPTION NOT THE RULE. HUMANA AS HER EMPLOYER GAVE HER A SPECIAL PLAN WITH COMPLETE ACCESS TO MOFFITT AT LOW COST.

BUT THE VAST MAJORITY OF HUMANA MEMBERS BATTLING CANCER IN THE TAMPA AREA DON’T GET THAT BENEFIT. THAT’S BECAUSE MOST OF THEM ARE SENIOR CITIZENS ENROLLED IN HUMANA’S MEDICARE HMO, WHICH DOES NOT INCLUDE THE MOFFITT CANCER CENTER IN ITS NETWORK OF AREA HOSPITALS AVAILABLE FOR CANCER TREATMENT.

PATRICIA GOLDSMITH (o/c): Humana Medicare HMO is actually the largest Medicare HMO in our seven county area, as well as the largest Medicare HMO in the state of Florida. In spite of that, we see virtually no Humana HMO enrollees at the Moffitt Cancer Center.

SMITH: When you as medical director are overseeing the formation of the treatment networks that your patients, uh, and your members are gonna get in any given area, are you gonna go for the best quality institutions or not?

DR. JERRY REEVES: We’re gonna go for the best who are willing to contract with us.

SMITH: And if they’re willing . . . ?

DR. JERRY REEVES: We have a balance. We are not able to meet everybody’s demand. We can’t be all things to all people. Our niche or our focus is affordable, quality healthcare.

nat sound/b-roll: Helen Boone and family, dog barks

NARR: AFFORDABLE HEALTHCARE WAS WHAT HELEN BOONE WAS LOOKING FOR WHEN SHE ENROLLED IN HUMANA’S MEDICARE HMO.

HELEN, A 75-YEAR-OLD RETIRED CHURCH SECRETARY, LIVES IN THE TAMPA AREA WITH HER HUSBAND ON A FIXED INCOME. TO SAVE MONEY, THEY DECIDED AGAINST A COSTLY MEDICARE SUPPLEMENTAL PLAN AND CHOSE HUMANA’S LESS EXPENSIVE HMO.

SMITH: What did you think was included in your plan with Humana?

HELEN BOONE: Well, I thought that at our age, you know, I thought if we were sick and needed to go to the doctor and go to the hospital, that I just assumed everything was covered.

nat sound: Helen Boone & family

Helen & BetsyNARR: AFTER AN ANNUAL MAMMOGRAM COVERED BY HUMANA, HELEN LEARNED SHE HAD STAGE ONE BREAST CANCER. HER DAUGHTER BETSY WILLARD KNEW THERE WAS ONLY ONE PLACE TO SEND HER MOM.

BETSY WILLARD (v/o): The minute that she was diagnosed with cancer, we knew that we wanted her to go to Moffitt Cancer Center. … This was the best care for my mother. That’s what we were gonna get.

Medical Training Video

NARR: BETSY WANTED HER MOM TO HAVE LYMPHATIC MAPPING AT MOFFITT, THE SAME PROCEDURE VALERIE KENNEDY GOT.

WILLARD: Her surgeon in Brandon, the Humana surgeon, knew about the procedure. But Humana wouldn’t cover it.

DR. REEVES: Moffitt is a place that is especially good at taking care of the severest end of the scale of cancer patients. The great majority of our physicians are devoted to taking care of earlier stage disease. We don’t believe that 100% of all patients who have mild stage cancer must go to Moffitt in Tampa.

NARR: DR. JOHN RUCKDESCHEL, DIRECTOR AND C.E.O. OF THE MOFFITT CENTER, TAKES A DIFFERENT VIEW - ALWAYS GIVE CANCER THE BEST SHOT YOU CAN.

DR. JOHN RUCKDESCHEL (o/c): When you have a life threatening disease you would like to have the sense that the people who know the most about the disease have looked at your case - not an average case but your case - and said this is the treatment you need.

DR. RUCKDESCHEL: You know, acne’s one thing. You take one antibiotic, a different antibiotic. It doesn’t work, ok. But cancer? Your best shot’s your first shot. You really don’t want to screw it up the first time.

NARR: TO GET HUMANA TO PAY FOR MOFFITT, HELEN BOONE’S FAMILY FACED A LENGTHY APPEAL AND TIME WAS PRECIOUS….

WILLARD: We didn’t go through an appeal process with Humana. I just didn’t feel like we had enough time to —

HELEN BOONE: Wait around.

BETSY WILLARD: - to go through that painful process.

SMITH: Valerie Kennedy got breast cancer treatment here. How does her experience compare with that of say, normal HMO members or particularly with Medicare HMO members under Humana.

GOLDSMITH: Valerie Kennedy is very fortunate. She had the luxury of a choice - a choice that most Humana enrollees do not have.

b-roll: Helen Boone and Betsy Willard

NARR: INCLUDING HELEN BOONE. AND SO HER DAUGHTER HAD TO HUNT FRANTICALLY FOR ANOTHER HMO THAT WOULD COVER MOFFITT AND ITS IMPORTANT LYPHATIC MAPPING.

BETSY WILLARD: My worry is like, Am I doing this fast enough? She has cancer. Can she wait until November 1st for her new insurance to go into effect to see somebody? To start treatments or have surgery. …I had nightmares. I’m like, Oh my god. What am I doing? I’m delaying my mom’s treatment because I want her to have another health plan.

NARR: EVENTUALLY BETSY WILLARD TRACKED DOWN AV-MED, A NON-PROFIT FLORIDA-BASED HMO THAT WAS WILLING TO PAY FOR HELEN BOONE’S CANCER CARE AT MOFFITT. SO HELEN BOONE GOT MOFFITT CARE, AFTER ALL, BUT HUMANA LOST A MEMBER.

SMITH: In this particular case, the woman wanted to go to Moffitt so much, she left Humana and went to another plan. The other plan covered Moffitt and she got her care there. How do you react to that?

DR. REEVES: Well, the patient needs to decide what they want and to get that within their personal best interest as they see it. We will not be able to please 100% of the people 100% of the time.

DR. RUCKDESCHEL: If I ran 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. But the minute you got sick you said goodbye. I’m out of here. I’ve taken your money to insure 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, that’s a wonderful racket from my point of view.

STANDUP: FOR THE CHRONICALLY ILL, FROM YOUNG CHILDREN TO SENIORS, DEPENDING ON FOR-PROFIT HEALTH INSURERS WITH AN EYE ON WALL STREET CAN SOMETIMES BE RISKY.

A MARKET-DRIVEN PLAN LIKE HUMANA PAYS FOR LIFE SAVING CARE DURING HART McCONNELL’S EARLY MONTHS. AND IT USES DISEASE MANAGEMENT TO IMPROVE CARE FOR CONGESTIVE HEART PATIENTS, WHEN IT SERVES THE BOTTOM LINE.

BUT WHEN CARE AND COST COLLIDE, AS WITH SOME STROKE VICTIMS, CANCER PATIENTS, OR CHRONICALLY ILL CHILDREN, THE COMMITMENT FROM A DISTANT INSURER CAN CRUMBLE OVERNIGHT…. LEAVING FAMILIEIS SCRAMBLING TO PAY FOR THE CARE THEY SO DESPERATELY NEED.

BUT THERE ARE ALTERNATIVES. TRADITIONAL MEDICARE, NON-PROFIT HMO’s, AND A FAR DIFFERENT VISION OF MANAGED CARE REPRESENTED BY KAISER PERMANENT, WHICH COMBINES HEALTH INSURANCE, DOCTORS, AND HOSPITALS IN THE SAME PLAN WITH DOCTORS CALLING THE SHOTS AND COMMITTED TO A LIFETIME OF CARE. WE’LL EXPLORE THAT APPROACH IN ANOTHER PROGRAM. I’M HEDRICK SMITH. THANKS FOR BEING WITH US.

Dip to black

In Memoriam

Credits

ANNOUNCER: To learn more about this program, and ways for patients to get better care, visit PBS Online, at the internet address on your screen.

To purchase a copy of all or part of Critical Condition, please call 1-800-553-7752, or write to the address on your screen.

ANNOUNCER: A presentation of South Carolina ETV.

ANNOUNCER: Principal funding for Critical Condition was provided by

The Robert Wood Johnson Foundation.

Making grants to improve the health and healthcare of all Americans.

Major funding provided by

The California Healthcare Foundation.

Additional funding provided by

The Rockefeller Brothers Fund

And the Charles E. Culpeper Foundation.

ANNOUNCER: This program is part of the PBS Democracy Project.

ANNOUNCER: This is PBS.





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