Watchdog blasts HMOs for denying services, high costs

A Health Ministry ombudsman is blasting the Health Maintenance Organizations for denying their members numerous medical procedures and examinations as well as charging chronic patients large sums of money.

More than 8,000 complaints were filed against Israel's HMOs during 2007 and 2008, according to a report recently released by the Health Ministry Ombudsman Etti Semama, in charge of complaints against HMOs.

Commenting on 116 complaints regarding the HMOs refusal to fund PET imaging - which shows whether a tumor is benign or malignant - Semama called on HMOs not to deny critical examinations to patients with diseases included in the services covered by the health insurance.

Semama also called on HMOs to hold open debates with the doctors referring patients to various treatments and to "avoid a restrictive approach regarding the services included in the health insurance." She recommended updating the medications covered by health insurance within fixed time periods, which allows for long-term planning.

Semama blasted the HMOs' practice of charging chronic patients large sums of money for medication and repaying them expenses beyond a certain amount over the course of six months. Instead she recommended fixing a monthly sum and exempting patients from payments that exceed it. Many patients complained of having trouble making payments and waiting for the HMO to reimburse them.

The highest number of complaints and the highest rate of justified complaints per member were filed against the Leumit HMO (5.9 complaints per 10,000 members). This was followed by Clalit (5.3 per 10,000 members), Meuhedet (4.4 per 10,000 members) and Maccabi (2.8 per 10,000 members).

In 2007, 4,254 complaints against the HMOs were filed with the Health Ministry - 23 percent of which were found justified, 41 percent unjustified, 14 percent were solved and 22 percent remained undecided.

The ministry also received 3,235 complaints pertaining to patients who had transferred from one HMO to another - 28 percent of them were rejected.

In 2008, the Health Ministry received 3,883 complaints about HMOs, 24 percent justified, 39 percent unjustified; 17 percent were solved and 20 percent remained undecided. The number of complaints pertaining to transfers from one HMO to another rose to 5,170, but 51 percent of them were dismissed, the report says.

Leumit received the highest percentage of justified complaints (2.09 for every 10,000 members), followed by Meuhedet (1.67 per 10,000 members), Clalit (1.38 per 10,000 members) and Maccabi (0.68 per 10,000 members).

The highest number of complaints regarding treatment with medication were filed against Meuhedet, followed by Leumit, Clalit and Maccabi.

Over 2007 and 2008, 1,659 complaints were filed in reference to the HMOs refusal to fund treatments with specific drugs - 161 complaints pertained to Plavix treatment for heart patients, 44 about treatment with immunoglobulins (a class of antibody that has only been found in mammals), 36 about Cymbalta (medication for treating depression and pain) and 22 about medical treatment with Botox (botulinum toxin).

Forty-one complaints pertained to funding genetic tests, 50 to funding dental treatments and 20 to funding amniotic fluid tests.

Among the complaints detailed in the report, 12 came from heart patients detailing the HMOs' refusal to approve a cardiac defibrillator implant, despite a 2006 Health Ministry regulation.

"Even if the HMO disagrees with the ministry's position, it must deal with the issue in the acceptable channels and not conduct the struggle in this improper way," the ombudsman writes.