Making Prevention Universal
Healthline: Sometimes HMOs decide to go find healthier enrollees.
Zingale: That is a slightly different problem involving adverse selection or what is sometimes called “cherry picking.”
The answer to your first question is to make access to preventive services universal. Even though most health plans are doing a good job with preventive health, where there are holes, you fall into the problem you’ve just articulated. If 90 percent of the plans are providing good diabetes screening and prevention, but 10 percent are not, all of the plans know that that 10 percent of risk might add up on their account books at the end of the day.
That is why I think Governor Davis and the Legislature acted wisely when they mandated prevention services in the area of diabetes, cancer, and mental health in the package of bills that created this department.
Healthline: You’ve been a big champion of mental health parity. What is in the new package of bills addressing this?
Zingale: Mental health was one of the preventive health interventions included in the package of mandated benefits. I believe this reflects the understanding that mental health care is preventive health care. The fact remains, as I said earlier, modest investments could prevent huge expenditures and suffering down the road. This is as true about mental health as any other area of health care.
Healthline: What about care that is not preventive? There are tensions inherent in the HMO concept葉he drive to keep costs down and ration care can be at odds with what individual patients want or need. What about patients’ rights to sue or have recourse to obtain independent reviews when HMO decisions don’t go their way?
Zingale: I have been very direct about the fact that I am most interested in preventive health care and preventive regulation. In other words, I think we need to begin with what can be done to prevent harm to patients in the first place用reventive regulation.
We can spend the next hundred years fighting over resources and damages for harm that was done today. Or, we can invest those same dollars early and avoid spending all those precious health care dollars on litigation and advertising wars and the other things that health care dollars are wasted on. I’m interested in seeing how we can stimulate those investments to keep people healthier, to prevent damage from being done, and to prevent care from being denied.
Healthline: But the battles are already going on. Whatever screening and prevention is in place, people will still be fighting over denials of care. Your predecessor body [the Department of Corporations] went out with the parting shot of a million-dollar fine against Kaiser for the delay of care in a case involving a ruptured aortic aneurysm.
Is this the kind of thing your agency will be tracking? Governor Davis, for example, was accused of trying to gut the right-to-sue provisions of the HMO bill package by making sure that all external review processes are exhausted before patients are ever allowed near a courtroom. Is the ability of patients to have independent review of their claims about denial of care important to your department, or is this only the horse being out the barn door and down the road apiece in terms of your prevention initiatives?
Zingale: The independent medical review included in the HMO reform package is at the heart of the advances for the State of California. That is the mechanism by which medical experts will have the final say as to what kind of care is or should have been available. That is an enormous gain for consumers.
The department is responsible for building the infrastructure that will provide medical review for consumers and facilitating the implementation of that system. We’re now looking at criteria for who should be providing such a review to make it absolutely certain there is no conflict of interest. We will also facilitate consumer inquiries.
Healthline: What about helping consumers navigate the maze of information about providers and plans and options in general?
Zingale: We talk about the principle of shared responsibility. Government will not solve every problem. The new department wasn’t created to be a giant bureaucracy micro-managing the health care system in California. The department has a clear set of responsibilities, but so do the health plans, providers, and consumers themselves. This experiment will only work if everyone takes responsibility for it. Consumers have the responsibility to learn more and to take some responsibility for their own health.
The department will publish the first report card on managed health care, which I hope and expect will provide user-friendly data on how well health plans are serving California.