THE GOOD, THE BAD, AND THE ANNOYING Published June 17, 1996 Previous columns by Harry Goldstein	Like 45 million other American working people, I'm enrolled with a healthcare maintenance organization (HMO). Mine claims over 1.9 million members. I've been with this HMO for the last four years and have very mixed feelings about its performance. On one hand, I pay very little out of my pocket for healthcare -- $5.25 out of every paycheck (pre-tax) and $5 co-payment to see a doctor or to get a prescription filled. It's cheap, but you get what you pay for. HMOs are built around a primary care physician, a doctor who is responsible for every aspect of your healthcare. You must obtain a referral from this person every time you need to see a specialist. This is where the red tape starts -- and depending upon how complicated your treatment is, the fun may never end. With just one exception, I haven't seen the same physician at my HMO-sanctioned clinic twice in a row in the past three years. More than once, the doctor I've latched onto as my primary care physician has moved onto another job, leaving me in the lurch when it came time to get the all-important referral.
Coughing blood was a minor inconvenience compared to the nine months prior to surgery.	Coughing blood was a minor inconvenience compared to the Kafka-esque nightmare I've lived over the last nine months while trying to obtain treatment for obstructive sleep apnea. To the clinic staff, I was just an annoying voice over the phone, another memo in the fax, a face in the multitudes patiently drumming their fingers on the reception desk, waiting for paperwork. I was finally referred to a pulmonary specialist who referred me back to my primary care physician who referred me for a sleep study and to an ear-nose-throat specialist who evaluated my condition and in turn referred me to a former student of his, a head and neck surgeon who had pioneered a new sleep apnea procedure that uses lasers to disintegrate the uvula and tonsils, thereby facilitating greater air passage during sleep. After several weeks of shuffling paper through the HMO mill, making courier runs on my own time, carrying CAT scans and X-rays from one set of doctors to another, and making dozens of phone calls to make sure the paper work was going through, I was ready for cutting. Then two days before I was to go under the knife, someone from the clinic called me at work and asked me why I was getting surgery without approval from my primary care physician. In fact, the approval forms were already in the mail to me and I told her this. She replied that she had no record of any approval going out to me.
"Don't tell me the clinic suddenly cares."	This was the last straw. I lost control. "You give me the damn runaround for nine months and now, two days before I'm supposed to finally get some relief, you're going to tell me you have no record of all my work in getting this approved?" Taken aback, she stammered with an apologetic remark. "Don't tell me the clinic suddenly cares. And don't screw this up for me." She hung up and never called back. Two days later, I was on a gurney. 50cc of Benadryl bubbled through me and made my tears boil. My HMO's PR spin doctors might say the bottom line is that I got my surgery and my apnea is cured. I say the bottom line is that I lost countless hours of work time; that one entire sleep study was deemed worthless because the inexperienced technician who administered the test hooked me up in such an uncomfortable manner than I never fell asleep; that I endured more than my fair share of anxiety during the three week period that it took my HMO to decide whether or not it would pay for my surgery; that the company's refusal to foot the bill for the entire recommended procedure is inexplicable; that the call I got yesterday from the anesthesiologist's office (informing me that they never received the proper paperwork and that my bill remains unpaid) proves that the bottom line is yet to be determined.
I finally got proper care, but plenty of people don't.	But, at least I finally got proper care. There are plenty of people who don't -- and some of them have been testifying before a House subcommittee that is holding hearings on the country's managed health care system. Other people have told their stories to New York City public television station WNET, which has an excellent web site devoted to exploring health care from several perspectives. With more and more companies turning to managed care to help them cut costs and with the possibility that health care might once again turn into a political football this election season, it might be worth your while, whether you're on an HMO now or will be in the near future, to become an informed consumer. Especially when you consider that you might be buying cut-rate goods. Harry Goldstein is a writer and editor living in Manhattan. His work has appeared in Utne Reader, American Book Review, Promethean, AltX, word.com, and other periodicals. © 1996 Harry Goldstein, All Rights Reserved