Did your doctor deny you treatment for a bonus?

Author Subject: Did your doctor deny you treatment for a bonus?
Del Posted At 21:31:58 02/23/2000
Wednesday, February 23, 2000- USA TODAY

HMO cut costs at the expense of care, plaintiff says

In Supreme Court case, woman says bonus policy led to medical emergency. Lawyers warn of damage to industry.

By Richard Willing

WASHINGTON -- Cindy Herdrich was in agony, bent nearly in half by pain that her doctor thought was an infection.
A week would pass before the doctor ordered a test, and another week before her HMO could schedule it. By then, the source of her pain was clear: It wasn’t from an infection, but an inflamed appendix that burst and needed emergency surgery.
The misdiagnosis was bad enough. But Herdrich then discovered her HMO paid bonuses to doctors who ordered fewer tests, raising the question of whether her doctor stinted on exams that might have caught her condition.
Nine years later, Herdrich’s case is the first Supreme Court challenge to HMO policies that critics charge sacrifice patient care to reduce costs.
But HMO lawyers say the case, to be argued today, threatens the financial underpinnings of a healthcare system that provides coverage for 160 million Americans.
The bonus policy, Herdrich says, presents a conflict of interest between a doctor’s pay and his duty to a patient.
"I was flabbergasted; I had no idea such a policy existed," says Herdrich, 42.
Had she known of the bonus policy, Herdrich says, she" wouldn’t have selected that HMO."
Herdrich’s case seeks to determine:
Whether plans that award bonuses to doctors for not ordering tests force doctors to choose between health care and profits.
Whether patients can sue their HMOs under federal law over their managed-care policies.
Currently, federal law blocks most such suits. Herdrich and her lawyer are trying to carve out an exception to the law.
The Supreme Court case will be heard against a backdrop of escalating attacks on the managed-care in industry. Class-action suits have been filed against virtually all of the major HMOs, including Aetna, Humana, Cigna, Kaiser Permanente and PacifiCare Health Systems. In Congress, a House-Senate committee is scheduled to consider a "patients' bill of rights" that would amend federal law to permit HMOs to be sued in state courts.
"This case may turn out to be a lot more important than the patients’ bill of rights," says Gregg Bloche, a physician and a lawyer who teaches public health policy at Georgetown University Law Center in Washington. "The public attention generated by this case is going to make people much more aware of these incentives. Then perhaps they will vote with their feet."
Managed care seeks to contain employee health-care costs by capping payments to physicians, restricting choices of doctors and hospitals and letting administrators determine how much care patients should receive. In 1988, 71% of patients with insurance were covered by traditional, fee-for-service plans, with a generally unrestricted choice of doctors and hospitals. Ten years later, only 14% were in such plans. The rest, an estimated 160 million Americans, are covered by managed-care plans.
Plans that include cost-cutting incentives such as bonuses are common, Georgetown’s Bloche says. Herdrich’s lawyer, James Ginzkey of Bloomington, Ill., argues that the bonuses set up a conflict of interest.
"When doctors are paid more to do less, it’s not surprising when they do less," Ginzkey says.
Herdrich was a 33-year-old legal secretary in Bloomington when she went to her HMO, Carle Clinic, complaining of pain in her lower right abdomen. At first, her doctor, Lori Pegram, believed Herdrich had a urinary tract infection. At a later appointment, the doctor said Herdrich might have an ovarian cyst.
Herdrich was scheduled for an ultrasound eight days later, at a hospital 60 miles from her home. By then, her inflamed appendix had burst, and she was forced to undergo emergency surgery. Her recovery required a two-week hospital stay and bed rest at home.
Carter Phillips, representing Herdrich’s doctor and her HMO, says it is "laughable" to suggest that a "physician would screw up a diagnosis" to receive a bonus. The risk of a doctor being sued for a large malpractice award would outweigh the reward of a bonus, he said.
Phillips, the managing partner of the Washington office of the law firm Sidley and Austin, said Herdrich was not given an immediate test because the doctor "made a mistake on the diagnosis," not because it helped the doctor win a bonus.
A ruling for Herdrich could undermine the managed-care industry’s ability to reduce insurance costs, Phillips says.
Current law does not allow patients to sue HMOs over care decisions. Herdrich is suing under the Employment Retirement Income Security Act, a 1974 law that regulates private employee benefits plans. Her lawyers say HMO bonuses could compromise the special "fiduciary" duty that benefits plans have to their participants. By a 2-1 vote, a panel of the 7th Circuit Court of Appeals in Chicago agreed.
Sherwin Kaplan, a Washington- based labor lawyer and a former Department of Labor attorney, says that despite her sympathetic story, Herdrich may have trouble prevailing.
"Was this truly a withholding of service or simply a misdiagnosis?" he asks. "You can’t take a misjudgment on the part of a doctor and build it into a (federal employment law) case
Herdrich, who won $35,000 from her doctor in a state malpractice suit, says she is pursuing the federal case to press a point.
"You have a right to know who your doctor’s working for," she says.
Fred Johnson Re: Did your doctor deny you treatment for a bonus? (Currently 0 replies)
Posted At 11:03:12 02/24/2000

Isn't this familuar, another point on the same issue. Acceptted condition, right elbow fracture. Go to the Hospital, diagnose, right elbow fracture. Sprained right wrist, patient denies neck problem. X-ray left side for comparison, one side looks simular to the other, isn't that the way it should be, assuming there is no left side problem.
Doctor is paid to fix right elbow problem, the quick and dirty fix is excise the radial head. Patient refuses this sergury, doesn't sound like it would work. Later developes more problems, right wrist begins to become the major source of pain.
Patient is obviously faking it, he did break the elbow, not the wrist.
A year later, the pain in the wrist & elbow is subsiding enough to start noticing pain on the left side, which was not effected in the fall. After all doesn't the paperwork say he fell auquardly on his outstreched right hand. Take an x-ray, and tell the patient there is no problems, on the left.
Shorten Ulna, 4 months later say patient is ready to start retraining. No further sergury will do any good.
Find another doctor, after the first refuses to do any more, is this because he was paid a flat fee for fixing right elbow.
Second doctor offers an oppinion, he sees a loose body, on the MRI which suggests, an arthroplasty might do some good. At the last minute he says now patient wants to remove plate in the forearm, and he also believes a partial resection will do some good. After being paid to fix the obvious, he also refuses to do any more.
After claim is closed, a lawyer steps in to help, he gets the claim opened on an aggrivation, which is not really an agrrivation at all, but a continuation of what has come before.
A third sergury, this time by a third doctor, whos says we will try to clean up the radial head but if it doen't work we will remove the radial head.
The IME, 3 months and one week after sergury, this no it all says, there is no more that can be done, on this day the patient is stable.
The take no for an answer, hard headed carpenter, who can no longer do the work, god intended, pays for his own unnessary old-age related cosmetic, distal ulnar resection combined with, carpal tunnel. Oh carpal tunnel where did that come from, didn't complain about that before, and the left wrist, the guy did fall auquardly on the right hand, the left must have been in his pocket. And carpal tunnel is an excessive use thing, doesn't have anything to do with trauma, he would have complained a long time ago, if he wasn't lying now about these new conditions. And of coarse the denials go on and on, will it ever end. More food for thought.
Marty Re: Did your doctor deny you treatment for a bonus? (Currently 0 replies)
Posted At 11:37:22 02/25/2000

Because of Presidential appointments during the Reagan and Bush administrations, we have a very conservative U.S. Supreme Court. This translates to their decisions being politically motivated and in many cases contrary to case law and constitutional standards.

Washington -- The U.S. Supreme Court gave little encouragement yesterday to a woman who sued her HMO over its practice of offering financial rewards to doctors as incentives to hold down costs.
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