Diabetic Undergoes Red-Tape Shock With HMO

Michael Harper, a Silver Lake resident who is a Type 2 adult onset diabetic and requires insulin to control his blood sugar levels, was delighted to read last January that a state law had gone into effect requiring HMOs to cover diabetic supplies.

The law by state Sen. Hilda Solis (D-La Puente) specifically includes the test strips and meter to monitor blood sugar several times a day and needles for insulin delivery devices.

In February, Harper started trying to take advantage of the new law, but, according to detailed letters he has sent me in recent weeks, he has encountered one frustration after another.

One problem seems to be an ongoing mix-up as his HMO and his medical group disagree over which is responsible for authorizing him to get what he needs and pass his inquiries back and forth.

Harper’s doctor suggested to me that the problems may have been compounded by the fact that Harper uses a special Novopen insulin pen and Novofine 30 needles to inject the insulin.

The doctor, Samuel A. Malayan of Glendale, said these are frequently used in Europe, but are not as common in the United States. They allow injections in public places to be done less obtrusively.

Malayan said some American HMOs have resisted paying for these, saying they are more costly and are a convenience rather than a medical necessity.

However, Cyndie O’Brien, a spokeswoman for Harper’s HMO, Inter Valley Health Plan, said it is not resisting paying for the devices Harper uses. “With us, if the doctor feels it’s necessary, then cost is not an issue,” she said.

Besides calling everyone concerned on the medical level, I checked with state regulators and Sen. Solis to see if they have been receiving other complaints that the law is not being observed.

The issue here appears simple: When the Legislature passes a law and the governor signs it, it ought to be enforced.

Dr. Sam Romeo, CEO of Harper’s medical group, University Affiliates IPA, which has 100,000 patients, including 7,000 to 8,000 diabetics, said Harper’s “is the only [such] complaint I’ve ever heard.”

But Harper’s doctor, who has many diabetic patients, said others have informed him it is difficult to successfully invoke the new law, and Solis said she too has received letters of complaint.

It may be that enforcement of the law by state authorities, like other HMO reform provisions that went into effect Jan. 1, has been impeded by delays in the Davis administration’s establishment of a new Department of Managed Care.

The department is scheduled to assume regulatory authority on July 1, or whenever next fiscal year’s budget actually goes into effect, and its director, Daniel Zingale, said last week that he certainly supports requiring the HMOs to cover diabetic supplies.

‘We will be addressing these kinds of issues,” he told me. “Why do we even have to mandate preventive health care? Given that we had to do that, let’s not have to ask the HMOs why they’re not complying with the law.”

Before Zingale takes over, oversight continues to rest with the Department of Corporations, traditionally regarded as a weak, procrastinating regulator.

That department’s spokeswoman, Julie Stewart, responded the day after I faxed the complaint.

‘We’re obviously troubled here by the lack of access to the care,” she said. “It appears that both the doctors’ group and the health plan are attempting to adhere to the law, but the process to get the supplies is quite cumbersome.

‘We forwarded this to our ombudsman .... We contacted Mr. Harper and he has now made a direct complaint to us. We’re going to look into it for him. Clearly, the gentleman is entitled to these materials and he should not have to go through these hassles.

One occurred when University Affiliates finally told Harper he could acquire the covered needles and test strips at the supply firm Apria Healthcare.

But, when approached, Apria said it hadn’t marketed diabetic supplies in years. Instead, it informed him, it sells oxygen and respiratory equipment.

CEO Romeo acknowledged his medical group had “a series of missteps here, none of which were intentional. We didn’t check the [Apria] catalog.”

But, he insisted, Harper should have known better than to try to arrange all of this on the telephone.

‘He should have come in and told us what product he was asking for, what needles or lancets he needed. Then we could have fixed it. These things can’t be communicated effectively over the phone.”

But, I thought, if everybody went in for every small item, rather than use the phone, University Affiliates could be overwhelmed.

Romeo faulted Harper for his complaint, because, he said, “the fault finding doesn’t create a resolution to anything. Let’s create a collaborative relationship. We have a problem. Let’s work it out.”

O’Brien sent me a written statement from Inter Valley.

‘We understand Mr. Harper’s frustration and we share in his disappointment that it was not clear what needed to be done to receive his supplies,” she said.

“Unfortunately, Mr. Harper’s situation was unusual and relatively obscure in nature. It is now clear that we could have approached this differently to ensure Mr. Harper had a clear understanding of the steps and process to obtain diabetic supplies.”

But Harper feels it was not he who was confused.

‘I would point out, I did make upward of a dozen phone calls,” he told me. “I spoke to various customer service reps, who always tried to be helpful. But after months I’ve received only an initial supply, and then they told me the authorization had expired and I had to reapply.”

It is such stories of confusion that impede the “collaborative relationship” medical executives like Romeo say they want.

Ken Reich can be contacted with your accounts of true consumer adventure at (213) 237-7060 or by e-mail at ken.reich@latimes.com