Tuesday, February 22, 2000

Prescribing a medicinal dose for the HMOs

The Cincinnati Enquirer

        Even back in the bad old days when we treated doctors as if they were better than the rest of us, we thought they should have to take their medicine if they made us sick.

        Patients put up with a lot, when you think about it. We cooled our heels for hours in their waiting rooms, reading musty copies of Ducks Unlimited and Colliers. We didn't ask questions. We didn't call them by their first names even when they called us “Honey” or, worse, “Mommy.”

        We thought our doctors were very special people. But we did not think they were above the law.

        Maybe our litigation trigger finger wasn't quite as itchy as it is today, but we knew we could take our doctor to court. Malpractice. Not too complicated, really. We could also recover damages if our plumber did shoddy work.

        And, in a delicious irony, we could sue our attorney if he didn't do a competent job when we asked him to sue our doctor or our plumber.

The wrong beans
        We can still sue our doctors, but right now we can't sue the companies that tell them how to practice medicine. At least not yet.

        Congress is wrestling with the “patient's bill of rights” and next week will begin pulling together a compromise from its two versions of managed-care reform. The House would lift the federal ban on lawsuits for Americans in health plans that fall under federal regulation.

        This would raise premiums by 4.1 percent, according to the Congressional Budget Office. That translates to less than $10 per month. The bill passed by the Senate, which includes some of the same provisions but does not expand the right to sue, would increase premiums by 1.3 percent. That's about $3 a month for a single person.

        The American Association of Health Plans calculates that permitting lawsuits would increase premiums by 10 percent. But sometimes the bean counters are counting the wrong beans.

        Last year, UnitedHealth Group stopped requiring doctors to get permission for most referrals, tests or hospitalizations. The company discovered it spent more money processing requests than it saved denying unnecessary treatments.

        Every doctor I know could have told them that. And if you doubt that your HMO is making medical decisions, I'd suggest you ask your own doctor what he or she thinks.

        You'll get an earful.

Dire warnings
        Some lawyers in Illinois have decided that there's another way to skin this legal cat. The Supreme Court will hear arguments Wednesday in the case of Cindy Herdrich, a legal secretary who says her HMO delayed tests and sent her miles from home for treatment in order to collect bonuses and save money.

        Meanwhile, her appendix burst.

        The case exploded as well. From its beginnings as a simple malpractice suit, it has become an exploration of the HMO and its “fiduciary duty” to the patient as defined by the Employee Retirement Income Security Act (ERISA).

        In other words, if an HMO links what it pays its doctors to the physicians' record of holding down costs, does it violate its legal duty governing employer-sponsored health plans? The high court is expected to rule this summer.

        The health care industry has issued dire warnings that our ability to sue our health insurance company could bring down the entire managed-care system. I hope that doesn't happen. This system serves millions of Americans. But it would be worse to dismantle the justice system, which serves us all.

        The Supreme Court ruled that a president of the United States is not above the law. Nor is Bill Gates and Microsoft. Nor is your family doctor. If our legal system is good enough for everybody else, it should be good enough for the managed-care companies. I'm not saying HMOs are bad guys.

        I'm just saying they're no better than the rest of us.

        E-mail Laura Pulfer at lpulfer@enquirer.com or call 768-8393. She appears on WVXU radio, NPR's Morning Edition and Insight's Northern Kentucky Magazine.