pictured with his wife, Julie E. Rones,
died as he waited for a liver transplant. (Family photo)
By David S.
June 24 1998; Page
liver cancer, Abdul Hakim Al-Warith of McLean wrote a
polite but worried letter to his HMO in February 1997 asking it to
its position and approve the potentially life-saving liver transplant
by specialists at Johns Hopkins University.
me and apprise me of the status of matters, as any further
delay in my treatment will have critical consequences," wrote the
banking consultant and father of five.
Al-Warith again wrote to Kaiser Permanente, his tone
more urgent. The HMO's unresponsiveness "is causing considerable mental
and emotional stress," he said.
Al-Warith poured his exasperation into a third letter. "[M]y
feeling is that Kaiser is stalling on a decision."
in May, Al-Warith appealed to the agency that oversees health
benefits for the families of federal and some District employees. The
took five days to review his case and told the HMO to pay for a
But by the time an organ became available, Al-Warith was too sick for
operation. He died the next day.
For people who
are already in a vulnerable position, challenging a health
plan's decisions on medical treatment can be a frustrating and lengthy
ordeal, especially because the plan typically has the final say.
is considering ways to tighten controls on HMOs, and one of the most
proposals is to guarantee patients the ability to appeal an HMO's
to an independent authority.
people with private insurance generally lack that
option. The federal government is working to provide external appeals
people in Medicare and Medicaid, the government insurance programs for
the elderly, poor and disabled, and 18 states have required insurers to
provide external appeals that vary in their scope and degree of
has proposed establishing an independent appeals process
for all consumers, as a patient's basic right.
the health insurance industry have resisted legislative
mandates, and others say health plans generally do a good job of
process that works as fast as it needs to is one of the
tenets of our own code of conduct," said Susan Pisano, spokeswoman for
the American Association of Health Plans, a major industry
see it differently. Managed-care companies' procedures
for handling disputes are, for the most part, "a mean-spirited joke,"
A.G. Newmyer III, chairman of the Fair Care Foundation, a patient
group in Chevy Chase. "They are structurally designed to take forever,
to be as inconvenient as possible, and to achieve the precise result
the insurers want -- that is, to get the policyholders to simply give
"willing to go the distance . . . the insurers very
often cave," Newmyer said.
said they recognized the frustration Al-Warith and
his wife felt but disagreed with the complaint that Kaiser was
"I think we
pretty consistent in our answer, but it wasn't the
answer they wished to have," said Larry Oates, Kaiser's associate
appeals that health plans offer consumers often reward
One patient who
triumphed was Rosalie Lynn, who contested her HMO's
refusal to pay a $60 podiatric claim.
rebuffed twice by the HMO -- first by the member services
department, then by the medical benefit review committee -- Lynn took
off from work as an administrative assistant at the University of
in College Park and drove more than an hour to CareFirst headquarters
Owings Mills, Md., to plead her case before an appeals panel of HMO
unanimously in her favor. "It was an easy decision,"
Chairwoman Teri Harrison said.
For $60, "most
people . . . would have gave up," said Lynn's husband,
Charles, who accompanied her to the hearing.
take the formal appeals route. CareFirst and FreeState
Health Plan, an affiliated Blue Cross and Blue Shield HMO, processed
than half a million medical claims last year and received only 703
said Antoinette Hopkins, director of member services for the two
plans may explain their grievance procedures in handbooks
sent to enrollees, some consumers say they are not aware of their
or responsibilities when a dispute arises.
is presented as a fair outside appeals process can be
far from impartial. That was the California Supreme Court's comment
year on an arbitration system Kaiser Permanente has used to resolve
in that state.
evidence that Kaiser established a self-administered arbitration
system in which delay for its own benefit and convenience was an
part," the court said in its opinion.
The court said
the appointment of the neutral arbitrator in Northern
California malpractice disputes took an average of 674 days in the
instead of the promised 60 days or less and that it took almost 2 1/2
on average for a case to reach a hearing.
steps to improve the arbitration system, and the HMO
wasn't necessarily responsible for the delays, Kaiser Vice President
As a member of
Kaiser's HMO in the Washington area, Al-Warith was not
subject to the arbitration system. Told he had about a year to live, he
challenged his health plan internally -- and then pursued the external
appeal available to those covered through the Federal Employees Health
coordinated Kaiser's review of Al-Warith's case, said the
HMO was following sound medical judgment throughout the dispute because
Al-Warith's cancer was too advanced for him to receive a new
after Al-Warith had been diagnosed with liver disease,
the director of the liver transplant program at the University of
at Birmingham studied his test results for Kaiser. Applying the
criteria, the Alabama expert concluded that Al-Warith did not qualify
a transplant because his liver had four lesions.
opinion, Al-Warith went outside the Kaiser system to
Johns Hopkins Hospital in Baltimore, where by late December doctors had
concluded that he was indeed a valid transplant candidate.
the conflicting opinion from Hopkins, Kaiser began reassessing
On May 1, more
than 10 weeks after Al-Warith began his anxious correspondence,
Oates sent his first written response.
"Our process at
present is to continue to review his [Al-Warith's] care
requirements and re-evaluate our decision as necessary. We have not
his right to pursue care outside of our system," Oates wrote to the
In late April
early May, the HMO got the results of an analysis
it had sought from an outside "ombudsman" group. One cancer specialist
concluded that a transplant offered "the best hope" of extending
life, Oates said. Another gave "a qualified yes" to the question of
a transplant "might be beneficial," Oates said.
Even with the
operation, neither consultant gave Al-Warith more than
a 20 percent chance of surviving for five years, Oates said.
With his health
-- and his odds of recovery from surgery -- deteriorating,
Al-Warith appealed to the U.S. Office of Personnel Management. Covered
by his wife's government health benefits, he was able to turn to a
authority in a way that commercially insured patients generally cannot.
Even so, this appeal wasn't as independent as some patient advocates
necessary, because, like other employers, the OPM could face rising
if it ordered more care.
It took the
federal agency less than a week to respond. Kaiser "re-evaluated
the claim and determined that a liver transplant is appropriate for
medical condition," the OPM informed Al-Warith on May 14. When doubts
about Kaiser's intentions, the OPM on May 20 formally ordered the HMO
By the time
Al-Warith was hospitalized at Hopkins on May 25, 1997, his
illness was too severe for doctors there to perform a transplant.
flew Al-Warith to the UCLA Medical Center in Los Angeles, where he died
on July 2.
insurance struggle continued. Even after his death, a collection
agency sent him notices this year for unpaid physician bills. In
Hopkins was still owed $18,477.98 as of last week for Al-Warith's
stay, according to an account statement, and UCLA was owed more than
according to lawyer Jacqueline Fox, who represented
waiting for an itemized bill from Hopkins and will pay for
all the care, a spokeswoman said.
transplant surgery would have saved Al-Warith's life
can't be known. "I think that's a possibility," Oates said.
But Kaiser had
weigh the odds, because there aren't enough organs
for everyone who might benefit, Oates said. Transplant eligibility
vary from hospital to hospital, he noted.
widow, D.C. government lawyer Julie E. Rones, said one lesson
of this saga is that any external appeals process "needs to have teeth"
-- the ability to enforce its decisions.
The Office of
Personnel Management has the power to drop health plans
from its program, a potentially disruptive step, but OPM officials said
it has no lesser means of penalizing health plans.
For his part,
Kaiser's Oates supports the concept of an independent
of cases, it'll support our decision-making processes.
And, where it does not . . . it's going to give us an opportunity to
Richard Drezen contributed to this report.
Copyright 1998 The Washington Post Company