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Worth reading, contracts with HM ...

Posted Nov 10 2008 4:21pm

Worth reading, contracts with HMO insurers...every HMO doctor has them...do these contracts interfere with the level of care received?  Is this a catch 22 with insurers telling the physicians what they can and can't do...and this patient worked for the doctor and probably saw more of an inside track than what most patients see...and questions did she get quality health care or did the business of HMO contracts get in the way...BD 

"Not every HMO uses all these measures to pressure docs into limiting care. But you can bet the contract your doctor signed with your HMO contains a few."  . Docs "became slowly compliant out of fatigue and utility.""The drug I prescribe may not be the best one for you — but it's what your HMO will cover." "If you have to go to the hospital, I may turn your care over to a doctor who works directly for the HMO."image

ROSEMARY DUDLEY TRUSTED her HMO doctor. After all, she worked in his office as his nurse. So, in late 1997, when he told her a CAT scan showed no recurrence of the cancer she'd battled for two years, she believed him. And she wasn't surprised when he insisted that a referral to a cancer specialist for the knot on her jaw wasn't necessary. Her health maintenance organization paid him thousands in bonuses for holding the line on such costs. 

About four months later, Dudley came to know something else. Her cancer had returned, crawling beneath the skin on her face. A January 1998 CAT scan — ordered by another physician — showed it had moved to her lungs and to the bones in her ribs, hips and legs. It was terminal.

Two years later, the 67-year-old Texas woman decided to sue her doctor and former employer — who testified that the reason he didn't like referring to the oncologist was because she interfered with his patients' care. Dudley, along with a separate group of patients and a group of Fort Worth-area physicians, also sued the HMO that offered docs the financial incentives, Harris Methodist Health Plan. Harris paid almost $6 million to settle those two class-action suits, plus resolved Dudley's case in an undisclosed settlement. Meanwhile, the Texas Department of Insurance fined Harris $100,000, citing a state law banning financial incentives that provide an inducement to limit necessary care. It ordered the HMO to pay another $3.4 million to doctors financially penalized under the plan. While it's generally difficult to sue HMOs for malpractice, the cases against Harris instead focused on treatment incentives and disincentives, which can be illegal under Texas law.

10 Things Your HMO Doctor Won't Tell You - Personal Finance News Story - KSAT San Antonio

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