Acting Commissioner William Kenefick
Department of Corporations
3700 Wilshire Blvd., Suite 600
Los Angeles, CA 90010-3001
RE: Distillation and Rebuttal to closure of RFA 7478, letter of 9/2/97, file no. 933-0002.
Following are excerpts from original Chronological Summary of Events submitted to DOC June 4, 1997. Crossed-out are my opinions, impressions or comments. The complete Summary, which the DOC's Chief Administrative Officer retains, is sixteen pages and ranges in period from late December 1996 to September 1997. The DOC's letter of September 2, 1997 refers to these records as being insufficient.
TUESDAY, JAN 21st - I am supposed to meet with Kelly White who is in charge of UCLA outpatient affairs regarding Buc's possible transfer by Maxicare, her HMO, but she never calls me. I'm under the impression that Maxicare's Dr. Lee is applying undue pressure to bear on Buc's three physicians to have her transferred before she is stable or safe to move out of UCLA ICU.
WEDNESDAY, JAN 22nd - She is lost for the day, UCLA telling me that she has been transferred, and Daniel Freeman Marina Hospital telling me that she is not there. In fact, unbeknownst to me, while signing documents at UCLA, she has been wheeled to an undisclosed room not more than fifty feet away, perhaps saving the HMO as much as $1,800 each day..
THURSDAY, JAN 23rd - She is transferred with a high 103o fever, a skin rash over her entire body, arriving at 3:00 o'clock in the afternoon, and left alone and unattended in a cold Room 310, some distance down the hall from the nurse's station, her pulsatile stockings and therapeutic boots laid aside. When I finally arrived at 9:00 PM, the attending head nurse, Cobra, unaware of her condition and without patient records or inter facility transfer summary, could only comment on "how cute her hairdo was..." I was sickened when I saw her lying there, looking like Mahatma Gandhi during an extended fast. For six hours she had laid in sheer neglect. This sudden change from aggressive neurological care to nonattendance coincides to the Maxicare's contractual assumption of care, which then continues uninterrupted for months, up and until Buc's move to Casa Colina.
What these records fail to mention, is the exact nature of this patient's
illness and corresponding medical expectations. Equally important,
and still apparently unknown to the DOC, is the degree of injury affecting
subsequent care. Thirdly, and equally important is the type of surgery
this patient has received. It is called GDC surgery for SAHs.
Ten years ago, all patients died from SAHs and subsequent surgical clippings,
after all, it was open head surgery. GDC surgery does not require
opening the head and its mortality is only 4%. This what my wife
Constance, aka: Buc, received at UCLA within six hours after collapsing
on the tennis court.
In light of these revelations at the cutting edge of medical technology,
I completely lack confidence in the DOC's knowledge about my wife's condition,
both internally among their own staff of primarily attorneys and managers
as public servants, but as well among their selection of third party specialists
to review and rule on this RFA.
I believe my uncertainty rests in the knowledge, that my wife's surgical
treatment was rare and generally unknown to physicians and medical workers.
This became crystal clear to me when many specialists and case workers
told me that they had seen thousands (actually three-thousand was once
quoted to me at Freeman Hospital) of cases like my wife's. Bear in
mind, when Buc received her GDC surgery, Boston-Harvard Medical School,
Irvine Medical School and UCLA had collectively treated less than 150 patients
of grade V SAHs.
Again, I ask you to keep in mind the severity of my wife's injury.
An aneurysm explodes inside her head at the basal tip, producing a subarachnoid
hemorrhage (SAH), the size of a baseball, the brain being push to one side.
As part of post-surgical procedures, she must safely eclipse a twenty-one
day period of vaso-spasms. This is true for most patients even with
lesser grade SAHs. It is a biological process unrelated to the demands
of an HMO. January 21st, the day these vaso-spasms are supposed to
subside, is the day Maxicare wants to move my wife from an advanced tertiary
facility to another facility wholly unfamiliar with her exact condition
and corresponding medical requirements.
Vaso-spasms are a critical life threatening body reaction to certain
types of brain injury. Physicians use Doppler monitoring to observe
their advent and decline. They can occur at any time during and after
this twenty-one day period. They are of critical concern for at least
two reasons. If uncontrolled, they can cause damaging strokes to
the brain. Their treatment, a matter of containment, is risky to
the patient, requiring the extreme elevation of blood pressure in an already
injured brain and the moving of the patient from neuro-surgery to the cardiovascular
section.
Armed with this medical knowledge, one can readily understand the essence
of time to this patient and her retention significantly longer at UCLA,
and thus how, the plan's carrier, Maxicare of California, Inc., failed
to provide continuity of care as promised to the families and citizens
of the State of California per California Code of Regulations 1357.08 Required
Basic Health Care Services, subdivision (b), (d) Standards 1367:
the plan shall furnish services in a manner providing continuity of care.
It also demonstrates a real lack of concern for this patient.
It is one thing to lose track of a patient with a broken finger, but to
lose track of a patient of such serious magnitude injury for two days is
unconscionable.
It seems to me that either the DOC's response completely disregarded
information presented by me to them, or that they somehow construed California
Code to specifically allow the disruption of one extremely critical patient's
ongoing care and essential medical treatment, so that the Health Plan under
investigation would be found in compliance with the Knox-Keene Act.
WEDNESDAY, MAY 14th 11:45am - I return Carmel's call to me from Casa Colina. She tells me that Robyn (Buc's case worker) said that Buc's coverage was retroactively terminated April 1st. I was shocked saying that Robyn does not work for Maxicare. Carmel said that she works for Prairie Group, which is correct. I told Carmel that I should have this in writing. "No way! It's not going to happen Mr. Webb; we need to know today"!
The previous chronicle, also submitted to the DOC, requires some explanation.
I believe that it was overlooked by the DOCs investigators because
of its vagueness.
It might be my failure to provide the DOC with interpretations of these
chronicles as well as others, which led to the case's out-of-hand dismissal.
However, I do believe that if the DOCs investigators required clarification
or explanation of the brief and factual diary I maintained, they should
have asked. I'm sure at times, that the DOC sometimes requires explanations
of patient records provided by doctors and hospitals. At the time,
I believed that it was my responsibility to provide the DOC with evidence,
not an explanation.
This very short passage tells about how Maxicare of California, Inc.
phoned Prairie Group, the assigned Provider, and told them that because
they are going out of business in the State of California, this patient
will no longer be covered retroactively to April 1st, two weeks before
they told anyone.
If such was the case, then Maxicare of California, Inc., is in violation
of 1367 g, that medical decisions by qualified medical providers are not
administrative nor fiscal.
What makes this particularly troubling is that the DOC seems to refuse
to recognize, acknowledge and respond to this unbelievable and significant
allegation concerning an ailing carrier1, who once before, not more than
a decade ago, did the same thing right under the DOC's nose
Such persistence of the omission of action by the government, particularly
in light of our present Democratic governor's coziness with big business
in establishing a central committee regarding HMO regulation, indicates
to me that the Knox-Keene Act will not be enforced.
This also speciously refutes the DOC's denial letter based on insufficient
evidence, since two of my own business clients can independently attest
to Maxicare's alleged withdrawal from the health care field at that time.
It should be noted that this letter, dated September 2, 1997, shortly
follows on the coattails of a July 23rd MRI finally scheduled by Maxicare
of California, Inc., after more than six months absence of radiology testing.
This was the first MRI authorized by them, and in my opinion not done on
the patient's behalf, but as a defensive action, no doubt, presumably designed
to appease the DOC's investigation and coincident moratorium.
Compared to UCLA, prior to Maxicare's assumption of their control over
my wife's treatment and care, she was receiving numerous daily scans.
Once she was forced out of UCLA, which was one of four tertiary hospitals
worldwide familiar with my wife's surgical procedures, routine and essential
scanning ceased. In fact, Maxicare's contracted hospital, Freeman
Memorial, was so unfamiliar with GDCs, that they were uncertain if to proceed
with this one and only MRI at their facility. They were concerned
that the powerful super conductive magnetic field, which is always turned
on, might dislodge her coil. I explained to the radiologist that
the coil is made from a noble metal, platinum, and is not ferrous.
It should be noted, under California Code, basic health services per
(b) of Section 1345 (3) specify ongoing radiology, which no doubt, by intent,
is inclusive of MRIs.
Also within Section 1345 (b), as specified under those Standards set
forth in 1367, i, 4, though my wife's plan included Home Health, none of
her carriers honored those benefits as the plan move originally between
Aetna, Maxicare, CareAmerica and Blue Shield. To this day, though
she is eligible and has amassed more than two hundred and forty days of
nursing care, the plan has not provided a single nurse for more than one
hour throughout the two years she has been home!
This neglect to the patient was implemented by the sudden and unexpected
dismissal of Maxicare's outpatient nurse during the preparation for home
care and nurse's training and has been fully documented in materials given
to the DOC, again representing the unfortunate absence of State intervention
and enforcement per California Code of Regulations 1357.08 Required Basic
Health Care Services, subdivision (b), (d) Standards 1367: the plan
shall furnish services in a manner providing continuity of care.
Recently, Department of Corporations personnel, namely Melissa Moon,
Helen --------, ____________ _________ and ___________Woods have resolved
the dispute over FiberSource nutrition with CareAmerica. A case was
delivered yesterday, so we haven't run out. Again, I thank them for
all their efforts put forth. Thank you so much.
Helen ------------ spent over an hour on the phone last week, calling
from her home, explaining how the carrier's benefits for an employee plan,
expire when certain conditions are met, such as the final expiration of
COBRA and the parent company going out of business. Though I acquiesce
to the DOC's ruling in this regard, one can only question the meaning of
the phrase "unlimited benefit coverage" if in fact, such benefit coverage
is NOT unlimited. Does this not fly smack in the face of Knox-Keene
Act regulations concerning advertising, solicitation and evidence of coverage
accurately disclosing benefit expectations?
Another example of cutting hairs, is my wife's bed.
Prior to her dismissal to home care, I learned a lot about hospital
beds. There are highly specialized beds, some costing as much as
$120,000. But, in asking her respective PCPs under her plan,
none would make any recommendation, asking instead, what I might have in
mind. Eventually, when it was time for her to have a bed, she got
what was called a fully motorized bed, despite missing some critical functions.
No doubt I signed all the delivery papers concerning this bed, which
CareAmerica has misconstrued in saying that the family is delighted in
its delivery. I even bet you have a paper in your keeping mentioning
this in order to assure the DOC that our family is delighted with the outcome
of this matter.
Now, besides missing certain critical functions and having a bamboo
pole I erected as its IV pole, and the first bed leaning to one side, dropping
ball bearings on the floor, making a lot of grinding noises, once or twice
collapsing, cutting my pants legs as I snag them onto its sharp metal edges
and hardly being specified by any physician in its design and purpose,
it seems to have passed the DOC's inspection with flying colors.
How did this happen?
The original outpatient specialist assigned by Maxicare told me that
she would make sure that Buc got the right bed as a durable good covered
benefit. She said that there are sand beds, air beds, beds that rotate,
all kinds of beds to alleviate the possibility of bed sores as well as
other physiological and mental problems associated with patients confined
for inordinately long periods to their beds without moving. What
we got was basically equivalent a 1945 WWII military bed for those with
temporary medical conditions, not permanent confinement.
As time progressed, we began to receive rental charges for the bed
which came to more than $8,000. Eventually the DOC discovered this,
and came to bear on the respective providers, thanks to Melissa Moon.
I was hoping by now that the DOC would recognize that my wife was sleeping
on not much more than a motorized straw mattress, a bed type clearly defined
by the Knox-Keene Act as being unacceptable.
However, all of this began to be swept under the carpet with apology
letters from Blue Shield and the bed provider, Apria Home Health, rescinding
all charges, whilst in the process of making a deal with each other.
On several instances letters referred to the bed as being fully motorized,
which it is not. It is a far cry from the many possible and very
appropriate beds for this patient. But, I have given up as one more
time, the DOC has failed to enforce the true spirit of the provisions of
the Knox-Keene Act.
I have drawn your attention to these several examples in the one last
hope that you might reopen Constance's RFA so that she may receive her
rightful benefits she desperately needs in order to recover.
I pray is there please not something you might still do for this poor
woman, where without your protection, she will yet surely die?
Yours in trust,
Joel Webb on behalf of Constance A. Webb
910-B 20th Street, Santa Monica, CA 90403, (310) 828-2292
copies to:
Secretary Dean R. Dunphy - Business, Transportation and Housing
Agency
Senator Tom Hayden
Commissioner Chuck Quackenbush, Department of Insurance
Senator Barbara Boxer
Senator Dianne Feinstein
Representative Henry A. Waxman
Representative Sheila James Kuehl
Governor Gray Davis
File: DOCRFA7478