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Press Release

by Jorden N. Pedersen, Esquire

The recent Health Maintenance Organization (HMO) reform legislation passed by the United States House of Representatives on October 1 is a step in the right direction for the consumers of this State and great nation. However, there is already speculation about what essential components of the bill will be taken out and bargained away to get it passed in the Senate.

Our political leaders should not stop now. If they stop now, they will be doing their constituents a great disservice. This bill and others like it came to fruition because, everyday, HMOs are making life and death decisions regarding medical care, yet they are not legally held accountable for these decisions. If they are going to make decisions like licensed practitioners, they should be held accountable for those decisions like licensed practitioners.

In addition to the Federal legislation, which may or may not pass, New Jersey has the opportunity to join Texas and California, two of the nation's largest states, in working to pass its own HMO reform legislation in Assembly Bill #1606 (A1606). The Bill is sponsored by Assemblymen Guy Talarico (Bergen) and Steve Corodemus (Monmouth) and would improve the HMO patient relationship by giving consumers the right to sue their HMO if serious injury or death resulted from denied or limited care. The legislature can and should take the lead in moving on A1606 as quickly as possible.

At this point I would like to cite just two cases that underscore the need for this legislation. The first case concerns a 23 year-old female, and member of the now defunct American Preferred Provider HMO. She went to her physician on numerous occasions complaining of stomach pain. He never ordered tests nor an ultrasound, which would have revealed gallstones. Six months later, the young women was dead from acute pancreatitis - a direct result of not having her gallstones removed.

The second case concerns a young couple's infant with severe congenital birth defects. The child's condition required tubes for breathing and eating and around-the-clock nursing care. The mother was a fourth-year medical student and the father was a second-year law student. They petitioned their HMO for 16 hours of nursing care. The HMO countered with eight hours, threatened to decline further coverage and suggested that the mother drop out of medical school and learn the skills needed to care for her baby. Leaving medical school would have triggered school loan payments for whi& there was no income and a loss of eight years of education and training.

Contrary to popular opinion and insurance company rhetoric, the New Jersey and Federal bills are intended to encourage HMOs to become more responsible for the decisions they make and more diligent when contracting for providers. These actions will likely lessen the need for costly litigation.

That's right, I said lessen the need for costly litigation. FIMO reform legislation is now the proverbial sword of Damocles. This legislation will provide the impetus for the HMOs to get back to the business of providing health care, not stock dividends. Consumers won't need to instigate lawsuits when they are granted the health care services they need, want and for which they have contracted and paid.

Since Texas gave patients the right to sue managed care plans for malpractice in 1997, only five lawsuits have been filed by the four million Texans enrolled in HMOs.

Finally, with that in mind, it is time for the insurance companies to begin delivering the quality health care American employers are paying for and give consumers the services they readily deserve. Once insurance companies do that, there will be no need for lawsuits.