Los Angeles Times Profiles Department of Managed Health Care on Its One-Year Anniversary

Today's Los Angeles Times examines California's Department of Managed Health Care, which may provide a "glimpse" into how expanding patients' rights to secure a second opinion about a medical decision may "play out for most Americans." Just over one year ago, the Legislature established the Department of Managed Health Care, the "only stand-alone agency of its kind in the country," to provide an outside review of HMO complaints. The agency, headed by Daniel Zingale, serves 23 million HMO members -- the nation's largest managed care market -- and employs about 100 people, including nurses, lawyers and customer service representatives. At the department's "nerve center" is the consumer hotline, which receives about 15,000 calls per month. Of those calls, the department's representatives field about 6,000, filing between 300 and 400 formal complaints, while an automated service handles the remainder. According to the Times, the department has "broad powers to intervene" if it decides a "major violation" has occurred. To date, the department has fined Kaiser Permanente $1 million for failing to provide adequate care; "forced" PacifiCare of California to pay overdue claims to providers; and taken over daily operations of financially struggling Maxicare Health Plans.

Based on interviews with patient advocates, policy makers and lobbyists, "there is broad consensus" that the department is "fulfilling Zingale's pledge" to create an responsive agency that is effective for consumers. At the same time, some advocates say that there are patients receiving inadequate care whom the agency "cannot or does not help." Ron Pollack, executive director of the health consumer rights group Families USA, said, "These external review boards are trying to be objective, and many consumers just don't have the capacity to present their case like the health plans do." John Metz, chair of the California Consumers Health Care Council, added, "The department is at least partly relying on the health plans' account of what happened to patients, but they have no way to verify the facts provided by the plan." As a result, patients' rights experts agree, the "deck is still stacked in favor of the health plans." So if similar programs elsewhere in the country are to make managed care "work" for consumers, Pollack said, they need a strong leader, like Zingale, a clear mandate to advocate for patients, and "lots of help" from patient consultants. "We know these patient assistance programs can make a big difference for people and the can often get things solved before they reach external appeal," Pollack said (Carey, Los Angeles Times, 7/30).