When Care is Denied : Bureaucracy and cost controls are the culprits that Californians typically blame when HMOs deny them medical care. Here are two patients’ story: : THE WALL FAMILY / Limited Choice

DANA POINT —  It seemed so easy when Lanci and Greg Wall switched to an HMO last fall.

The Dana Point couple figured they would save money. Their two young sons would keep their pediatrician. And Lanci, a breast cancer survivor whose left breast was removed seven years ago, felt assured that she could keep her oncologist.

But the Walls learned the hard way how HMOs work.

Though the boys could go to the same pediatrician, the plan from Greg’s work did not fully cover Lanci’s oncologist. She feels as if she has moved to another state, having had to sever all ties with the doctor “who knows exactly what my tumor felt like.” She blames her own ignorance about HMOs and what she describes as misleading information from Aetna.

An Aetna spokesman says Wall’s primary care physician determined that it was not medically necessary for her to see an oncologist for annual checkups because her cancer is beyond remission. What’s more, Wall apparently did not understand that she could have seen the oncologist on her own, with the insurer paying for 80% of the cost after she picked up a $300 deductible.

Before signing up, Wall--a housewife and former saleswoman who does the family’s budget by computer--compared Aetna’s HMO and a preferred provider plan the family had been using. Aetna’s monthly premium for family coverage was $82.61--a third less than the other plan. Aetna also covered wellness checkups and shots for their sons, excluding a $5 charge per office visit; the other plan had not covered those and other services, costing the Walls $800 in out-of-pocket expenses last year.

Impressed, Wall skimmed through Aetna’s inch-thick directory of approved doctors. Her boys’ pediatrician and her oncologist were listed. “Great! I get to keep my doctors,” she remembers telling herself. To make sure, she says she called an Aetna representative, who indicated that she was right.

After enrolling, Wall contacted Dr. Edward Smith, a Dana Point general practitioner in the directory, to make an appointment and seek a referral to her oncologist, Dr. Neil Barth of Newport Beach. Smith said he believed that he could not refer her to Barth because their practices were affiliated with different hospitals.

Frustrated, Wall asked: “In other words, if the best doctor is the one I’m using, you cannot refer to him?”

Smith said he thought the doctors he could refer her to were just as good.

Next, Wall says, Aetna denied her request to see an approved oncologist for the annual checkup she had been having since her mastectomy. Smith told her he would handle the exams himself.

In retrospect, Wall says Aetna failed to explain fully the HMO’s limits on specialty care before the family signed up. She notes how the directory says, “Most of the time the specialists you’re referred to will be part of the same medical group . . . as your primary care physician.” She calls the sentence “misleading” because it seems to leave room for exceptions.

Will the family change plans?

Probably not, Wall says, because they are saving money on care for their sons. By early August, the family’s out-of-pocket costs this year totaled $113, compared with $800 for 1994.

As for her own care, she is deciding whether to let Smith continue as her doctor or pay out of her pocket to see Barth.

So far, Wall says, Smith seems conscientious. At her physical exam, he carefully checked her thyroid. The doctor, she says, found some swelling and asked her to come back for a followup.