When Leticia Walker went to a public aid office to apply for medical cards for her children a few months ago, she was approached by a representative from a health maintenance organization.
“He said it’s required that every person that receives a medical card from public aid now has to be under managed care,” said Walker, the mother of two.
“He had my case file in his hands. . . . My name was on top of it. . . . My case number was on top of it as well.”
Walker told him that she had had bad experiences with one HMO and didn’t want to sign up with another. When he failed to change her mind, Walker said, the man “wrote on top of my file, `Do not send medical card. Refuses HMO.’ “
Walker was within her rights to refuse his offer. For now anyway, it is not mandatory that people who receive public aid in Illinois join a managed-care plan–to say nothing of the fact that someone who is not a public employee has access to a recipient’s file.
But, according to Walker and several other public aid recipients, HMO representatives have been applying pressure and using outright deception to push public aid enrollees into joining their managed-care plans.
HMO officials strongly deny such allegations. And figures from the Illinois Department of Public Aid show that, while there have been abuses by HMOs, such incidents are not widespread.
Still, those who have been closely involved with the medical needs of these recipients–community health center officials around the city–say the marketing abuses are much more frequent than state figures indicate or HMO officials will admit.
Fear is keeping more public aid recipients from taking their complaints to state officials, said Patricia Pardee, a clinic administrator with the Chicago Department of Public Health. Recipients “just can’t take the chance that they’re going to lose their benefits,” Pardee said.
That these tactics are being employed against society’s most vulnerable members–many of whom are illiterate or who do not speak English, let alone understand the intricacies of managed care–they find especially galling.
These alleged incidents are of particular concern as Illinois gears up efforts to, in fact, enroll all 1.1 million Medicaid recipients into a managed-care program soon to be approved by the federal government.
“It’s kind of overwhelming to have an HMO go to a public aid patient’s house and they’ve never had any sort of agency come out to their home,” said Dinah Mirelez, clinical services director for the Claretian Medical Center at 556 E. 115th St. “That in itself is a marketing tool that is quite overwhelming.
“And then they give them the impression that if they don’t sign up, they’ll get their public aid checks cut, that they have to sign up. The pressure is on them. And they’re not used to those type of strong-arm tactics.”
Some public aid recipients have dropped out of the health-care system in frustration, health officials say.
Officials of HMOs under contract with the Illinois Department of Public Aid defend their sales practices and deny that they pressure clients.
“We do not have deceptive marketing practices,” said Ken Mann, vice president of marketing for American Health Care Providers Inc., which operates American HMO. “We teach our staff how to market.”
“If someone thinks that he got pressured into doing something by American, that is silliness,” Mann said.
An official for Chicago HMO, a unit of United Health Care of Minneapolis, acknowledged the possibility that a few marketers might use pressure tactics. But at Chicago HMO, he said, doing so would be in direct violation of company policy.
The company has implemented a rigorous training program to avoid such abuse, he said. Marketing representatives, for example, must undergo monthly training sessions for ethics and proper enrollment procedures.
In interviews with officials of community health centers and public aid recipients, Chicago HMO and American HMO were cited most frequently for marketing abuses. But that could simply reflect the fact that those two by far serve the largest number of public aid recipients in Chicago.
As of April, there were 175,000 out of a total of 450,000 Aid to Families with Dependent Children program recipients in Cook County enrolled in eight HMOs that have contracts with the state. Chicago HMO had the largest enrollment, with 130,000. American was next with slightly more than 29,000.
But even the companies with smaller enrollments drew complaints. Leticia Walker, for example, said her problems were with a representative of Louisville-based Humana Inc., which has enrolled 3,600 Cook County residents.
Like the other HMOs, Humana denied using strong-arm tactics. Such behavior would be “totally inappropriate” and grounds for firing, said Bill Werwonka, the company’s manager of corporate public relations.
An official with the Illinois Department of Public Aid said that while there have been confirmed abuses by HMOs, they have not been widespread.
The department received a total of 38 allegations of marketing abuses by HMOs in fiscal 1995 and so far in fiscal 1996, said Rob Miller, inspector general of the Illinois Department of Public Aid.
Of the 38, the department substantiated abuse in 12 cases involving two HMOs, though the agency would not say which ones. Eight of those 12 cases involved “misrepresentation by marketers in some fashion,” Miller said, and four involved “marketers actually forging” the names of public aid recipients to enroll them into HMO plans.
“We’re very, very tuned to this,” said Nelly Ryan, chief of the public aid department’s bureau of managed care. She said her bureau works closely with Miller’s office and provides a hot line for anyone who has a complaint about HMO marketing practices.
But she concedes, “It’s a tough market. They (HMOs) are competing with each other. . . . We’re all new in this.”
The state has taken steps to address a number of concerns that have been raised.
In March, the Department of Public Aid began contracting with the Human Resources Development Institute of Chicago to provide independent health benefits representatives to explain HMO coverage to potential enrollees, Ryan said.
Miller said the department is drafting new language for its contracts with HMOs to include stronger sanctions and penalties against any abuses.
So-called Medicaid HMOs are not new to the public aid picture in Illinois. Starting in the early 1970s, Cook County families who received assistance under the AFDC program could join HMOs on a voluntary basis.
Until a few years ago, the enrollment has been low. That began picking up in the last year or so, with enrollment growing by 33 percent a year, Ryan said.
By year’s end, she said, the number of Cook County public aid recipients enrolled in HMOs is expected to rise to 200,000.
That is a far cry from what the eventual total is likely to be. Gov. Edgar is seeking federal approval for his MediPlan Plus program, the aim of which would be to enroll all of the state’s 1.1 million poor people in HMOs.
Approval is expected, and implementation would begin next year.
Illinois would join a growing list of states seeking to put a lid on health-care costs by shifting coverage of their Medicaid recipients to HMOs. Under such risk contracts, the HMOs assume the responsibility of health-care service for a set fee. In Illinois that fee is $112 per patient per month.
Several states, however, have discovered that shifting to HMOs can be fraught with abuse, both in terms of marketing and quality of care provided. Iowa and New Jersey have banned door-to-door marketing by managed-care companies and the Florida legislature last week approved similar legislation.
In Chicago, officials of several community health centers say abuses already have started as HMOs jockey for advantage in anticipation of an even larger market under MediPlan Plus.
The most common abuse, they say, is pressuring potential enrollees into signing up with an HMO with the false threat that they will lose their medical coverage if they don’t.
Many recipients are promised that they can continue to go to their current clinics and see their old doctors under the HMO plan, which may or may not be true.
In Latino neighborhoods, the critics say, many have been told that they can use their HMO Medicaid cards anywhere in the country, and even in Mexico.
And once they decide they want to disenroll from their HMOs, it is taking recipients two to three times the usual time, which is 1 1/2 to 2 months, to do so, say the health clinic officials.
Pardee, administrator of the Chicago Department of Public Health clinic at 2938 E. 89th St., has collected 27 complaints from clients about HMO marketing practices.
“I have all kinds of stories here,” she said.
Probably the worst, she said, is that of a mentally challenged young mother of three, who has been a patient at her clinic “for years and years.”
Representatives from Chicago HMO reportedly came to the woman’s home “and told her that if she did not go on their plan, she would lose her benefits. So she was put on a plan and it turned out that it was so far away–in the suburbs–that she couldn’t get there.”
The woman showed up at Pardee’s clinic with sick children “and we saw them and helped them disenroll,” Pardee said, a process that took three to four months. Some time after that, the woman was enrolled in the HMO a second time.
“A lot of our patients are illiterate,” said Mirelez at the Claretian Medical Center. “So you have to communicate (with them) in a variety of ways.”
“We’ve also noticed a trend of (HMOs) only signing up the healthy people in the family,” said Mirelez.
“Patients don’t understand the whole concept of managed care,” said Gail Mitchell, director of clinic services for the Infant Welfare Society of Chicago, adding that she has received complaints about HMOs from 10 to 20 patients in the last few months.
“I’m not sure many of us do.”
The community health officials say they already are seeing patients fall through the cracks.
One young, Spanish-speaking woman had signed up for prenatal care at the Claretian Medical Center at 9119 S. Exchange, according to Maria Arteaga, perinatal coordinator at the clinic. The woman lived four blocks from the clinic and had been able to walk there.
After the woman delivered her third child, “a man with an interpreter came knocking on her door at home and they talked to her until she finally signed the papers for American HMO,” Arteaga said.
The woman said the HMO representatives told her she could continue to come to the Claretian center. “She said they circled it and they told her she could come here,” said Arteaga.
Instead, the woman was assigned to another health facility in the Roseland neighborhood, about 20 blocks away.
“She was even told that if she goes to Mexico and has an emergency in Mexico, that it would be covered there,” Arteaga said.
For some reason, the woman’s two older children were enrolled in the HMO, but not the baby. The baby is enrolled in the traditional Medicaid program. The woman has brought the baby to the Claretian center for treatment, but her two other children are behind in their inoculations because the woman is unable, or doesn’t want, to deal with the HMO, Arteaga said.
Ken Mann of American HMO challenges these stories.
At his company, Mann said, representatives “clearly indicate whether we have physicians and hospitals readily accessible to the applicant.” The representatives also go to great lengths to make sure the enrollees select a primary care provider.
And under the provisions of the state’s contract with HMOs, “we are not allowed to tell people they will lose their coverage” if they don’t sign up with the HMO, Mann said. “That’s grounds for losing” the contract.
“We are not doing that,” Mann said. “I don’t think they know what they’re talking about, not with American.”
