Daniel Zingale wants to take managed care back to its roots. As director of the newly created state Department of Managed Care, he is charged with overseeing regulation of the California health care industry and enforcing health care reforms passed last year by the state Legislature. The creation of his department was perhaps the most ambitious HMO reform in the nation and is being closely watched by other states.
Since taking office July 1, Zingale has created a hotline (1-888-HMO-2219) and Web site (www.HMOHelp.ca.gov), aimed at helping consumers solve problems and disputes with HMOs. It is the first step in fixing the health care system in California.
But his main mission, he said, is to put preventative care back into the managed care equation. It is, he said, the only way to save the managed care system and keep it profitable.
Zingale lobbied Gov. Gray Davis for his job. He has spent the last 10 years as a patient advocate in Washington, D.C., first for the American Psychological Association, where he helped create a model for mental coverage under HMOs, and later for AIDS Action. In his latter position, he gained recognition for shifting the group's focus from the treatment of AIDS to the prevention of the disease.
Now he hopes to do the same for California's entire health care industry.
Question: What's your first priority for this new department?
Answer: The big answer to that is, to improve the quality of managed health care conditions in California. I think the first step toward doing that is to build an effective and responsive HMO health center, so consumers can call the Department of Managed Health Care when they're having a problem they can't resolve and know that they'll get the kind of assistance they'll need. I'm very pleased with the progress we're making with that. We've done a great deal of training of the staff in terms of effective communications with the public and making sure they're equipped with the knowledge they need to empower patients in advocating for themselves.
Q: How has the public response been to the hotline and Web page so far?
A: I believe it's approaching half a million visits to the new Web site, which is terrific. And a large number of people are taking advantage of the assistance of the call center. What I'm most pleased with is, the obstacles to patient care have been resolved immediately. Take disagreements between patient and HMO about coverage; in the past, that dispute would sometimes be dragged out for weeks, months and into the realm of extended litigation. Oftentimes it hasn't been resolved until the harm to the patient is already done and you're trying to set a price on the harm to the patient. What I believe is happening now is, many more of those disputes are being resolved proactively on the front end, and the patient is being given care where appropriate before we get to that point.
Q: Preventative care is one thing you've cited as a way to solve the health care crisis. How can you make that work?
A: The whole founding principle of managed health care was to keep people well enough long enough to preserve health care dollars, so we could give optimum care to people who are very sick or who need immediate care. But it hasn't played out that way, for reasons that are complex. In part, it's because of the transitory nature of enrollees today. They join, belong to one health plan for awhile, then they may change employers or health plans or both, so there isn't the long-term financial interest there might have been to keep patients healthy. So we're looking for every angle we can on how to bring everyone to that common ground of preventative health and keep more people healthier for a longer period of time. I believe we can preserve the patient and also save dollars, so that there's less bickering about health care dollars.
Q: How do you plan to enforce the reforms passed by the state Legislature last year?
A: We're doing medical surveys on what the plans are providing and to whom. We also monitor complaints coming in to the HMO Health Center so that, for example, when we received a complaint from a gentleman with diabetes saying he is not being reimbursed for his test strips, which cost about $2 apiece, we're able to immediately contact his plan and say, "This is exactly the type of low-cost preventative intervention that is so important to everyone who has a stake in managed health care." And so far, we're getting good corrective action.
Q: How have the HMOs received you so far?
A: I would say, graciously and cautiously. It's no secret that my background is as a patient advocate, and there's also I think a recognition that AIDS advocacy is the gold standard of patient advocacy, so that appeals to some people and it may be a concern to others.
Q: Why did you want this job?
A: There were a number of reasons, both personal and professional. On the professional side, I worked for Gray Davis when he was controller of California; I was his chief of staff. I've always been watchful for an opportunity to work with him, and obviously his election as governor presented that. The other professional motivation is that I spent the last 10 years in Washington, D.C., as a patient advocate on behalf of mainly people with HIV and AIDS, and to be at the cutting edge of reform of managed care in California is a way to continue my commitment to patients. The third motivation was personal. I was born and raised in Sacramento. My parents are still there and they're getting older. I have a 5-year-old who I want to be closer to his grandparents.
Q: How have your first two months in office gone?
A: It's been exhilarating, because it's a rare opportunity to build and design a state organization from the ground up. And in this case, it's a state organization built and designed for quality of managed health care and financial stability of the health care system, and that's an interesting dynamic and important challenge.
Q: How does your experience as an advocate shape your role as director of this department?
A: Obviously, it means that I bring a passion about patient advocacy and an understanding that for many people, managed health care decisions are matters of life and death. For men, women and children with HIV and AIDS, the denial of a specialist or a drug formulary can be life and death. At the same time, I learned that there's a shared responsibility of improving the health care system.
Q: How so?
A: First and foremost, patients have to take responsibility for their own health and the health of their loved ones. And I believe to make preventative health care work, you have to have full participation of the patient, and the patient has to recognize their responsibility. A piece of responsibility clearly belongs to the providers. They could do a better job on preventative health than they're doing. And responsibility in California especially rests with the HMOs. It's the department's responsibility to try to be the control tower that brings all those together.
Q: How do you make patients more aware and more aggressive about getting preventative care?
A: I want to make sure the plans are doing everything they can to make patients aware of the preventative health benefits that are available to them. It's not enough to just offer an annual physical if the patient isn't aware that it's available. Or if there are other barriers, such as cost, we want to look at that too. I think an important step for the department now is to make sure that patients are getting information. We can partner with the plans to some extent to get the word out. We've developed a card that says, basically, "You have a right not just to health care when you're sick, but you have a right to stay healthy in the first place." We'll be asking plans to send those to their enrollees.
Q: Have you ever had problems with your own HMO?
A: I've belonged to an HMO most of my life. Like most people, (my experience) has mostly been mixed. On the whole, I think I've been well served.
Q: What is your biggest challenge as the director of this department?
A: The hardest part will be to persuade the stakeholders to rise above the old arguments over who gets how much of the old health care dollar pie and focus on the bigger picture, like improving preventative health care. It's hard to do that when there are financial strains and crises, so I'm working hard to get people to at least devote some of their time and energy to thinking about the ways we can work together and share responsibility. I just came from a meeting that brought major provider groups and HMOs and others together to talk about financial stability for one group and potentially others. From the response, I think everyone recognizes it's a new era and they want to be participants in that. Playing the old tapes doesn't work.
Q: What do you envision for the overall department?
A: I envision a lean and focused department that improves the quality of managed health care for Californians. I don't think government can solve every problem. I don't envision an ever-expanding vast bureaucracy to micromanage health care in California. But I do think we can take an important part of the responsibility in the situation.
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