From The Post • Gore Targets HMOs in AARP Speech (Washington Post, June 4) On the Web • Barbara Garvey page on Democratic Policy Committee's "Patients Before Profits" Site • Kaiser Family Foundation Study on Media Coverage of Managed Care • Physicians Who Care, Inc.'s HMO "Atrocity of the Month" Pages • Families USA "In Search of Health Care Horror Stories" Page

By Howard Kurtz
Washington Post Staff Writer
Monday, August 10, 1998; Page A1

In recent weeks, President Clinton has used the tragic death of Barbara Garvey to support his pitch for overhauling managed health care. Hillary Rodham Clinton has lamented the 55-year-old grandmother's death in her newspaper column. A number of news organizations, from ABC to Time, have cited the case among their examples of health care gone awry.

But such stories are often more complicated than they seem at first.

At a July 15 forum with the president, Garvey's husband said her HMO decided that the patient, suffering from a life-threatening form of anemia, should return to Chicago from a Hawaii vacation for a bone marrow transplant. He said the HMO told him that his wife had to have the surgery in Chicago or the health plan would no longer pay for her care. Garvey flew home but died days later.

There is, however, another side to the 1994 story. Garvey's doctor testified that Garvey ignored advice to come in for blood tests, instead traveling to Hawaii. The hospital there did not perform bone marrow transplants. The health plan dispatched a nurse to Hawaii to fly with Garvey to a major Chicago transplant center in hopes of saving her life.

"The problem is that medical situations are complicated," said Barbara Hill, president of the HMO, Rush Prudential Health Plans. "They don't just fit into a sound bite."

Much of the coverage of health maintenance organizations and their alleged shortcomings is driven by personal anecdotes – or "horror stories," as they are known in the trade – that dramatize the supposed heartlessness of cost-cutting HMOs. Journalists and politicians rarely get the other side, because health plans are barred by confidentiality laws from discussing individual cases. The patients who have publicly complained to the Clinton administration or news organizations can waive the confidentiality of their medical records, but often refuse to do so.

White House health policy adviser Christopher C. Jennings defended the anecdotal approach. But he said that Clinton has stopped talking about a breast cancer patient who told her story to the president but was later challenged by her HMO. "We're trying to be a little more careful than we were previously," Jennings said.

While some heart-rending anecdotes may be exaggerated or distorted, others are all too real, and they play into the frustrations of people who have had their own bad experiences with HMO bureaucracies. Nearly half of those interviewed in national polls say they have personally run into problems with their health plans or know someone who has. These range from routine billing disputes to a failure to approve important medical tests or access to specialists. Surveys show a widespread belief that cost-conscious health plans have reduced the quality of care.

For the news media, of course, tales of human woe are more compelling than abstract debates about cost and liability. And the insurance industry, which is spending millions of dollars to try to defeat managed-care legislation this year, is quick to claim that the use of emotional anecdotes is unfair.

"Reporters in any other situation wouldn't run with a one-source, unsubstantiated story from someone they weren't familiar with," said Mark Merritt, vice president of the American Association of Health Plans, which represents more than 1,000 managed-care groups. "Why should the rules be different when it comes to covering managed care, which happens to be under fire politically? Is that a rationale for throwing journalistic ethics out the window?"

The use of anecdotal evidence to score political points has long been a staple of Washington conflict. President Ronald Reagan regaled audiences with tales of a Cadillac-driving "welfare queen." Candidate Bill Clinton aired a 1992 campaign ad featuring a New Hampshire man who lost his health insurance when his 2-year-old son needed heart surgery. Sen. William V. Roth Jr. (R-Del.) successfully pushed legislation to revamp the Internal Revenue Service this year after staging hearings with taxpayers who said they had been mistreated by the agency.

The marketing of personal tragedy has become a cottage industry. Families USA, an advocacy group for better medical care, solicits "health care hardship stories" on its Web site and provides them "to print and television reporters, members of Congress, administration officials and other advocacy groups." The American Medical Association also solicits such anecdotes, saying: "You don't have to wait to tell the grandkids your managed-care war stories. The AMA wants to hear them right now." A group called Physicians Who Care features a managed-care "Atrocity of the Month." Another group, Consumers for Quality Care, faxes lawmakers a "Casualty of the Day."

"People can understand real-world examples more than they can understand a lot of the rhetoric in this debate," said Lorie Slass, communications director of Families USA. "A lot of reporters want to talk to folks who've had problems with managed care. If you're doing a story on an airplane crash, you're going to want to talk to the victims."

A Kaiser Family Foundation study of health care reporting from 1990 through 1997 found that 12 percent of newspaper stories and 31 percent of broadcast reports used anecdotes portraying patients or their families as victims. Industry executives are livid at what they see as one-sided reporting.

Charles N. Kahn III, incoming president of the Health Insurance Association of America, one of the industry's largest lobbying groups, called the coverage "totally hysterical ... some of the most biased and crackpot reporting I have seen."

Others say such anecdotes represent one side's version of a dispute. "A reporter may call with a lot of misinformation," Hill said, "but there's nothing we can do to correct it because the patient won't allow the records to be released." She is able to discuss the Garvey case because Garvey's husband has sued the HMO – a lawsuit not mentioned in most news accounts.

Some journalists are having second thoughts. John McCarron, a Chicago Tribune editorial writer, said recently that his paper led off a 1996 piece with "the obligatory horror story" about an Edwardsville, Ill., woman who had what was termed "a drive-through mastectomy" and suffered complications at home.

McCarron said he checked what the Tribune called her "nightmare story" and found that the woman's HMO would have paid for two or three nights' hospitalization across the river in St. Louis, but her surgeon did not want to make the trip. "I think the power of the anecdote, the horror story that we've all heard and become so tired of, is on the way out," he said.

Still, the administration, members of Congress and the news media have continued to focus on individual stories. On May 28, Clinton brought Ricka Powers, a Minnesota breast cancer victim, to the White House and greeted her with a hug. Powers said her HMO failed to diagnose her cancer after she noticed a lump in her breast, denied her requests for further tests, denied her access to a specialist rather than a general surgeon, and initially refused to pay her for chemotherapy.

"How can you let some person with the mentality of an accountant ... who will only see the number at the bottom line of what the chemotherapy costs, make the decision?" the president asked. Vice President Gore told Powers's story five days later to the American Association of Retired Persons in Minneapolis.

Gore's account was widely covered by news organizations, including The Washington Post. NBC's "Today" showed Powers accusing her HMO of refusing to pay for her chemotherapy.

George C. Halvorson, president of the HMO, HealthPartners, fired off an angry letter to Clinton: "You owe HealthPartners an apology for the disparaging statements you made about our organization. ... You presented as 'fact' a set of allegations from Ricka Powers and you did not bother to verify the validity or truthfulness of the allegations."

In an interview, Halvorson said he gave local reporters copies of waiver forms so he could release Powers's medical records, but that she refused to sign. He said his company had immediately given permission for an outside specialist to perform her surgery, despite the higher cost.

"The phone calls that she claimed, never existed," Halvorson said. "She had never been denied chemotherapy. No tests were denied. ... We take great pride in our breast cancer detection program. The concept that we would consider denying chemotherapy to a breast cancer patient is inconceivable. Our employees were deeply hurt."

Jennings, the White House aide, said it is not the administration's role to ask Powers to release her medical records. Besides, he said, "there is no HMO that says they did everything wrong. We try to make sure we have credible people whose experience is validated by some other person." But the White House stopped publicizing the Powers story after Jennings met with HealthPartners officials.

The Barbara Garvey case burst into public view on June 28 when her husband, David, recounted his wife's story at a Chicago news conference with Sens. Carol Moseley-Braun and Richard J. Durbin, both Illinois Democrats who were pushing legislation to protect patients' rights. Two weeks later, Garvey told the president his story at an American Medical Association forum.

That night, ABC's "World News Tonight" used a clip of Garvey telling Clinton: "To me, it was just obvious the HMO was more interested in saving money than in my wife's life."

"I've been using these horror stories as an illustration of the political climate," said ABC correspondent Linda Douglass. "I was careful not to put the details of anybody's allegations in that story."

The Chicago Tribune also reported Garvey's allegations without the HMO's side. Washington bureau chief James Warren says his staff "routinely double-checks" such charges and he thought it had been done on that story. "If we got snookered this time, we got snookered," he said.

Hillary Clinton recounted Garvey's charges in her syndicated column, also presenting them as fact. "Barbara Garvey deserved quality care," the first lady wrote.

On CNN's "Talk Back Live," Rep. Greg Ganske (R-Iowa) summarized the Garvey allegations, concluding: "Her family ought to have the right to recover."

Asked about the HMO's side of the story, Ganske said in an interview: "Those are things I can't make a determination on. ... I go on reports that I read in the press."

One exception was Time magazine, which reported Garvey's charges – one of them in a big headline – but included Rush Prudential's contention that Barbara Garvey had "resisted going to the doctor before her trip."

Garvey's physician, Charlotte Harris, recalled in a deposition when Garvey noticed bruises on her body before leaving for Hawaii. "I said, 'You don't have anything more important in your life [than] to go in and get these blood tests done. This could be a very dangerous situation' . ... I said, 'You should not get on that airplane until you've gone in to get another blood count,'‚" Harris said.

The family's attorney, John H. Alexander, questioned whether Harris actually spoke to Garvey. "They're blaming this lady for ignoring the admonition to come in. ... This lady didn't know there was anything seriously wrong," he said. Alexander said the HMO is using "technicalities" to evade responsibility.

Testimony was mixed from the doctor who treated Garvey in Hawaii, Kaye Kawahara. He said he decided she was stable enough to fly to Chicago, in part because Barbara Garvey told him "that she was afraid that her family would be financially ruined unless she returned to Chicago." But Hill says there was never any request that the surgery be done in Hawaii. While the flight was uneventful, Garvey was too ill for the operation.

News accounts could not even agree on the cause of death. The Chicago Tribune and Chicago Sun-Times said Garvey died of a cerebral hemorrhage; United Press International said it was an infection. The HMO says Garvey's death was caused by bleeding and respiratory distress from aplastic anemia.

The reason such accounts are trumpeted has less to do with complicated details than with the power of symbolism, as the White House fully understands. "The very existence of someone complaining about treatment in a health plan is a failure of the health plan," Jennings said.