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HMO OFFICIALS QUERIED ON COVERAGES, APPEALS

Representatives from area health maintenance organizations Saturday fielded questions ranging from coverage and patient rights to appeals processes during an HMO Town Meeting in Amherst.

Sponsored by the American Cancer Society and the Us Too! group of Western New York, the session also featured representatives of the state attorney general's office and several government programs, including Medicare Part B and Medicaid. More than 70 people turned out for the session in the Buffalo Marriott.

Nancy Davenport Ennis, president and founding executive director of the National Patient Advocate Foundation, was a featured speaker at the event and spoke about the current status of health care.

Ennis, who has met with President Clinton on health-care topics, touched on a number of issues, including inadequate reimbursement for chemotherapy, the failure to provide separate payment for supportive drugs and problems facing those who lack insurance.

"Currently, 20 percent of all our patient calls are employed, uninsured citizens who do not qualify for state or federal programs unless they spend down all assets to qualify for Medicaid," she said.

During the question-and-answer segment of the program, Joe Carrubba of the Town of Tonawanda, described his experiences as a patient and offered some advice.

"You should go to your doctor and be prepared," he said. "You can ask questions. You have to look after your own welfare."

Carrubba said when he underwent prostate surgery, his cardiologist recommended he have a local anesthetic. But when he got to the operating room, be realized they were preparing to give him a general anesthetic.

"You are your own advocate," he said. "Patients must arm themselves with knowledge. Taking care of your health is up to you."

Questions posed to the panel in written form included whether insurance companies restrict doctor recommendations and if doctors actually receive financial incentives for keeping down costs.

"A quick answer is 'no' and 'no,' " said Dr. Gregg Broffman of Health Care Plan. Edward McArdle, an assistant state attorney general, said such practices are illegal in the state.

Another question touched on the recent decision to restrict prescription drug providers to certain pharmacies, and if that will change.

Dr. Louis Irmisch, the Community Blue representative, referred the questioner to the insurer's legal department. As for the policy itself, he said, no changes are planned.

Dennis Galluzzo, president of the Pharmacists Association of Western New York, claimed credit for posing the question about changes in coverage for prescription drugs.

"Does not Blue Cross have a fiduciary responsibility to their subscribers to honor the contract which did allow them freedom of choice regarding their choice of pharmacies?" he argued after the meeting.

Galluzzo said he felt shut out of the meeting.

"This is the first time we had a chance to ask the question, and they didn't answer it," he said. "We don't get a chance to speak up. Pharmacists are a key part of health care."

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