Mismanaged Care?

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At the end of last year, Tim, one of Ted Mazer’s patients, came into his office with a large growth on his lip. It was cancer, but it hadn’t spread. Mazer, an ear, nose and throat specialist, told Tim it could probably be treated effectively with radiation. If that failed, surgery would be needed.

There was a small hitch. Mazer’s medical group—Mercy Physicians Medical Group East County—was closing in January 2002, which meant Mazer would no longer be an approved physician with Tim’s health maintenance organization, or HMO. A continuity-of-care provision in the law—which states that patients receiving treatment for certain medical conditions, such as cancer, can continue with their previous doctors—made it possible for Tim to begin radiation therapy with Mazer.

By mid-February, the tumor was growing again. Mazer asked for an approval for surgery and says it was days before Tim’s HMO contacted him, saying it needing more time to review the request.

“Three weeks later I get a letter from Sharp Community Medical Group informing me of Tim’s new doctor. [The HMO] had already paid a per-member fee for this patient and didn’t want to approve out-of-network care for him. It would cost them more money to have me do his surgery, regardless of what was best for Tim,” says Mazer.

He called and complained to the director of the medical group. “She insisted Sharp’s doctors could care for Tim,” says Mazer. By the time Tim saw his new specialist, the cancer had spread.

“The bottom line is I could have had him in an operating room within three weeks of seeing the tumor growing. Instead it was two months.” Because Tim was too ill at press time to give the required written consent for his HMO to discuss his case, we have omitted its name. However, a spokesperson at his HMO says the organization, like all California health plans, adheres to continuity-of-care laws and that members can always appeal a decision made by a medical group or health plan.

Tim finally had surgery in early May and mid-July. He lost much of his neck, jaw and half his teeth. Whether or not Tim’s perception of the situation is accurate, he believes his HMO “dragged its feet” when it came to letting Mazer handle his surgery.

Tim is one of 23 million Californians enrolled in HMOs, and his negative views of the system aren’t unique. Only oil companies are lower in the public’s perception than managed care, according to a Harris Poll released in late June. And it’s unlikely the recent U.S. Supreme Court decision rubber-stamping a patient’s right to an unbiased second opinion about treatment will change managed care’s popularity.

The ruling, issued June 20, upheld a law in 42 states (including California) entitling HMO patients to an independent medical review of HMO decisions. If the court hadn’t upheld the right, it would have been “the biggest blow to patient rights since the invention of the hold button,” says Steven Fisher, deputy director of California’s Department of Managed Health Care. Yet few take advantage of the review (where foot-dragging does not seem to be an issue—most reviews are done within 48 hours, even sooner if the case is critical). Although 250,000 people have availed themselves of the HMO Help Center in Sacramento this year, only 800 have sought an independent medical review. And doctors here say the system is flawed, no matter what safeguards are in place.

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