OMBUDSMAN PROGRAMS: Hotline Helps Patients ‘Navigate’ Health System
In only 18 months of operation, a "privately funded pilot program has helped thousands of Sacramento-area consumers navigate their health care plans," the Los Angeles Times reported. Funded through a combined $4 million grant from the Kaiser Family Foundation, the California Wellness Foundation and the Sierra Health Foundation, the Health Rights Hotline "offers educational outreach, a telephone help line and staff of counselors operating independently of doctors, hospitals and health insurers." Project Director Peter Lee said, "We're setting up the model for independent assistance." A breakdown of the 2,400 calls to the hotline over its first year -- July 1997 to June 1998 -- showed that 10% sought help obtaining coverage, 33% wanted further information about their health plan and 57% asked for help solving a problem. Lee said the ombudsman program was able to resolve 75% of such problems "at the level of the doctor and the medical group," without resorting to litigation or a formal appeals process. "Sometimes the resolution ... may be as simple as learning how to better use the system, to find out who is the right doctor or nurse who can make things happen in the medical group," he said. Dr. Yvonne McDowell, associate medical director for special projects at Health Net, said her company also has found the hotline data useful. "We at Health Net have the opportunity to learn about what the experience is of consumers far beyond our own membership and then incorporate that into our own strategy for providing better health care and service to our members," she said.
There Ought To Be A Law
John Rother, director of legislation and public policy for the American Association of Retired Persons, said the group is pushing for state Legislatures to mandate such programs and is pointing to the Health Rights Hotline as a successful example. "A lot of times what we find is not necessarily bad people running the plans, or people acting out of greed, but just as often we find confusion ... (for consumers and) for the people who are trying to provide services." Families USA Executive Director Ron Pollack said his organization is "deeply involved in trying to promote the concept of ombudsman" and will introduce legislation in Congress. He said ombudsman programs could be funded with a 15- to 20-cent surcharge on premiums, noting, however, that such programs have their limitations. "If what you want from a plan is not covered or is clearly experimental or clearly appropriate from a plan's point of view, you're not going to be able to call a number like this and get that turned around," said Rother (Allen, 12/28).