[Congressional Record Volume 142, Number 136 (Friday, September 27, 1996)]
[Extensions of Remarks]
[Page E1736]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




``SHE HAS NO IDEA WHAT'S GOING ON AROUND HER--HER PARENTS ARE BECOMING 
                            ALL TOO AWARE''

                                 ______
                                 

                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                      Thursday, September 26, 1996

  Mr. STARK. Mr. Speaker, I've just received a particularly moving 
letter about the problems facing American families in the era of 
managed care.
  Today, I introduced legislation which will address some of the 
problems mentioned in the letter--in this case, timely appeals of 
coverage decisions and provision of specialty care locally. But there 
is clearly much, much more to do. Managed care companies--by making the 
kind of heartless decisions described in this letter--are sowing the 
wind. They should not be surprised if they reap the whirlwind.
  Dr. Courntey's letter follows:

                                            Child Neurology, Inc.,


                                    NeuroDiagnostic Laboratory

                                   Mishawaka, IN, August 21, 1996.
     Hon. Fortney Pete Stark,
     House of Representatives, Cannon Office Building, Washington, 
         DC
       Dear Representative Stark: Today was another in a string of 
     very frustrating and sad days. It was different from others 
     in that the players made themselves so obvious. Often I have 
     no one in particular to rail against. Today was different.
       Stephanie is 16 months old. About 8 months ago she was 
     abused at the hands of her day care worker. Looking at her 
     MRI, only about 50 percent of her brain is left to perform 
     the functions that it takes the rest of us 100% to 
     accomplish. She may never behave appropriately. She will 
     never think efficiently. She struggles through her week of 
     therapies against the backdrop of seizures brought on by the 
     beating she endured.
       Her loving parents, having had a terrible time with 
     conceiving Stephanie, were initially the prime suspects in 
     her abuse. I was called to work with them shortly after they 
     arrived at the hospital. The mother and father were then told 
     that Stephanie was in a coma. They were not told that all the 
     rest of us knew; Stephanie might not survive. The swelling of 
     her brain, coupled with her seizures, might end her life. 
     They could see that she had been damaged, but could not 
     understand why anyone would want to accuse them of injuring 
     someone they loved. They were accused anyway. So, in addition 
     to having to weather their child's life and death fight, the 
     parents had to face multiple meetings with social workers, 
     psychologists, doctors, workers from the child protective 
     agency, and a detective from the state police.
       Now, 8 months later, I am looking at Stephanie's MRI and 
     listening to her father tell me that their managed care 
     company wants them to take her to Indianapolis to a panel-
     approved specialist, rather than the one that has been taking 
     care of her since her admission to the hospital. The local 
     specialist is boarded in the same specialty area as the one 
     in Indianapolis and, in fact, is boarded in areas above and 
     beyond the Indianapolis specialist. The HMO's position was 
     clearly stated to the father as financially driven. The local 
     specialist is not on their panel and they are not interested 
     in establishing a relationship with him--even though he is 
     willing to see the child for the same rate as the 
     Indianapolis specialist and is only 20 minutes from the 
     parent's home. It didn't end there.
       The father, distraught by his continuing ordeal with the 
     HMO, complained to his employer's personnel department about 
     the treatment his daughter is receiving. He was subsequently 
     pulled aside by his employer's Vice President and told that 
     there were 80 other employees that he had to think about. If 
     he ``kept complaining about the insurance they had chosen, he 
     could start looking for another job!''
       This happens day after day. HMO's seem to be content as 
     long as people are healthy. They define exclusions to 
     coverage more extensive then the scope of that which they 
     will cover. Mental health benefits, supposedly available, are 
     almost impossible to have approved. The level of concurrent 
     review is embarrassing for the patient and exhausting for the 
     health care provider. The number of times this review occurs 
     without the physician reviewer ever meeting or touching the 
     patient is beyond belief. The medical reviewer almost never 
     sees the patient. Moreover, diagnoses of the care-givers are 
     constantly called into question or second-guessed by people 
     employed by the insurance company without specialty training 
     in our area of expertise, not licensed to practice, not 
     trained in health care at all, and who are always 
     advocates for the company and never advocates for the 
     patient.
       Within the last several years, you introduced and 
     successfully passed an amendment to prevent doctors from 
     operating medical businesses outside of their specialty area 
     and outside of their total ownership (Stark). The public 
     interest is threatened by a doctor referring a patient to 
     another business for the purpose of their own financial gain. 
     However, managed care companies can create panels of 
     ``providers'' whose contracted fees are based lower than the 
     otherwise prevailing rates. The managed care company directs 
     the patient to the panel doctor who charges the managed care 
     company less and is rewarded for providing less. This occurs 
     for the purpose of the financial gain of the managed care 
     company. To be simple, this style of behavior clearly 
     violates the intent behind your amendment. These care 
     limitations, in turn, increase the managed care company's 
     profits, resulting in higher salaries for middle and upper 
     management.
       As a provider of health care, I see the soul of my field, 
     and medicine in general, being corrupted by improper and 
     mephistaphelean pacts with MBA's more concerned with numbers 
     than they are about the patients. I know how the CEO in the 
     managed care company would expect to be treated if it were 
     his or her daughter whose MRIs were on my wall. They would 
     never send their child 130 miles away for care that could be 
     provided better locally. They would seek expensive and 
     regular treatment for their tragically injured daughter. Our 
     only hedge against a worsening condition for a child like 
     this is to provide her with consistent and professional care. 
     The best care, if available, is always local. These 
     interventions may improve the child's future independence. 
     They may improve her parent's will to continue to build their 
     family.
       Assurance against abuse on the part of insurers should be 
     mandated. Insurance companies and managed care companies 
     should be held accountable by holding them medically and 
     legally liable for the medical decisions that they make under 
     the guise of ``financial decisions.'' They should not be 
     allowed to operate outside of ``safe harbors'' without 
     regulation. Insurance companies should not be in the business 
     of making medical decisions which affect patients * * * it 
     exemplifies an inherent conflict of interest. This basic and 
     fundamental conflict of interest is a state both unethical 
     and immoral.
       In the meanwhile, Stephanie is sleeping in her father's 
     arms. She has no idea what's going on around her. Her parents 
     are becoming all too aware.
           Sincerely,

                                     John C. Courtney, Psy. D.

                                       Clinical Neuropsychologist,
     Treasurer, Indiana Psychological Association.

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