184 Patient HMO Horror Stories
(The
List of Cases Continues to Grow)
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The material saved
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http://www.connix.com/%7Eharry/101-125.htm.
This web site is no longer in existence. There are
184 HMO,
not all Kaiser patient horror stories on this web page. The
following is the lead commentary, intact as originally presented:
"I have spent the
last year compiling a list of more than 175
managed care horror stories from news sources all over the country.
These stories are moving and powerful. Needless to say, the HMO
industry hates my cases, dismissing them as "anecdotal". HMO
executives, puffed up with righteous indignation, declared months ago
that they would start collecting positive managed care stories. Well,
what exactly is a "positive" managed care story? Someone got the care
he needed and paid for?
I
have posted these horror stories on the
internet to help get them to as many people as possible. My hope is
that our lawmakers feel enough pressure from their constituents to
introduce and pass legislation reining in the power of the insurance
companies. This collection of stories has already made the rounds on
Capitol Hill, and a number of newspaper and magazine reporters have
contacted me about them. I feel that this kind of dissemination is
necessary. Feel free to copy these cases and distribute them.
I thank everyone who
has sent me
managed care horror stories and comments via e-mail and fax. "
1.
A 27-year-old man from central California was given a heart transplant,
and was discharged fromthe hospital after only four days because his
HMO wouldn't pay for additional hospitalization. Norwould the HMO pay
for the bandages needed to treat the man's infected surgical wound.
Thepatient died.
(Mitchell,
Larry, "Butte urged to immunize against potential HMO ills," The
Enterprise-Record, Jan.21, 1996.)
2.
A four-year-old girl ran a high fever following a five-hour hospital
stay for a tonsillectomy(considered an outpatient operation by HMOs.)
Her mother took the girl to her HMO pediatrician,who didn't take the
girl's temperature, didn't examine her throat, and didn't refer the
girl back to thesurgeon -- a routine procedure for post-operative
problems. The girl died of a hemorrhage at thesurgical site.
(Sherman, William,
"Tragic
tonsillectomy for girl, 4," New York Post, Sept.
20, 1995.)
3.
A mother in Atlanta called her HMO at 3:30 a.m. to report that her
6-month-old boy had a feverof 104 and was panting and limp. The hotline
nurse told the woman to take her child to the HMO'snetwork hospital 42
miles away,bypassing several closer hospitals. By the time the baby
reachedthe hospital, he was in cardiac arrest and had already suffered
severe damage to his limbs from anacute and often fatal disease,
meningococcemia. Both his hands and legs had to be amputated. Acourt
subsequently found the HMO at fault.
(Rabin, Roni, "In
Case of
Emergency," Long Island Newsday, Feb. 11, 1996.)
4.
A newborn boy died after an HMO-mandated one-day maximum stay in the
hospital -- eventhough his mother expressed concern about his health
prior to the forced discharge.
(Sherman, William,
"What his
parents didn't know about HMOs may have... Killed This Baby,"New
York Post, Sept. 18, 1995.)
5.
A Texas woman with a disabled 11-year-old son was told that her managed
care plan wasretroactively denying payment for all oxygen, nursing
care, respirator supplies, speech therapy, andincontinence supplies
because, the case manager said, "Your son costs too much money." The
casemanager is then quoted as saying that the boy's parents should "put
him in an institution in Wisconsin,and since your husband works for an
airline, go fly to visit him." Of course, the managed care planwould
not pay for the institutionalization.
(Letter to the
California
Nurses Association, in response to "Patient Watch" advertisements
placedin 1996 in a number of national and local newspapers: name of
writer available upon request toCNA.)
6.
A
Medicare HMO beneficiary with symptoms of pneumonia and a heart attack
was denied admission to a hospital, with the concurrence of his HMO
primary physician. The man died on theway to see the doctor.
(Rosenthal, Harry,
"HMOs not
popular with Medicare recipients," Today's Sunbeam,
Jan. 7, 1996.)
7.
A Washington, D.C. woman complaining of a post-surgery sore throat and
nausea went back tothe hospital for treatment. Her HMO allowed a
relatively inexperienced physician's assistant toexamine her and
prescribe some medicine and bedrest. The woman died at home that night.
Shewas suffering from a punctured esophagus received during surgery a
little more than a week earlier.
(Hilzenrath, David
S., "Costly
Savings: Downside of the New Health Care," Washington Post,
Aug.71995.)
8.
A Milwaukee HMO and a medical laboratory were ordered to pay a $10
million settlement totwo families after pap smear misreadings led to
the deaths of two women. According to testimony ata Congressional
hearing on health care fraud, the owner of the lab also served on the
HMO's boardof directors, and was given his competitor's bids in
advance. The lab later pleaded no contest toreckless homicide.
("No Contest In Pap
Smear
Misreadings," Washington Post, Dec. 7, 1995.)
9.
A woman took her son to her HMO network doctor, saying the boy had a
broken leg. Thedoctor did not X-ray the leg, and insisted twice that it
wasn't broken. Only after the woman tookher son to an emergency room
was an X-ray ordered. The break was diagnosed and set.
(Ress, David,
"Getting to the
nitty-gritty," Richmond Times-Dispatch, Mar. 18,
1996.)
10.
A 15-year-old girl with a serious knee injury was taken by her parents
to a PPO orthopedicsurgeon. The surgeon said there are two kinds of
surgery for such an injury, traditional scalpelsurgery and
state-of-the-art laser surgery, which is considered the most effective
method. Theinsurer would not pay for the more expensive laser surgery.
A company claims supervisor wasquoted as saying, "We are not obligated
contractually to provide Cadillac treatment, but only atreatment."
(Tomczak, Garrett,
"Ignorance
isn't bliss on HMOs," Minneapolis Star Tribune,
Mar. 23, 1996.)
11.
To help harried doctors cope with managed care arrangements, Harvard
Medical School offersa course providing tips on "streamlining" a
comprehensive physical exam to save time. Onesuggestion is to skip the
usual practice of looking in the patient's ears if the real concern may
besomething else.
(Uhlman,
Marian and Susan FitzGerald, "Is your doctor looking out for you? Or
your insurer?"Philadelphia Inquirer, Mar. 24, 1996.)
12.
A New York man twice got authorization from his HMO to go to the
nearest emergency roomfor mysterious stomach pains. After discharge, he
was told his plan wouldn't pay the $3,220 billbecause the care was "not
preauthorized." The New York Insurance Department's Office ofConsumer
Affairs forced the company to pay the bill.
(Sherman, William,
"Play By The
Rules," New York Post, Sept. 19, 1995.)
13.
In February 1991, a man with a high fever and suffering night sweats
went to his HMO primarycare doctor, who took less than five minutes to
pronounce the man's ailment the common cold. Stillsick and losing
weight, the man later visited an out-of-network doctor who ordered a
blood test andsent the man to the hospital. The man ended up spending a
month in the hospital receiving treatmentfor hepatitis. The HMO refused
to pay the $6,300 bill because the man broke the rules and went outof
the network to receive proper medical care.
(Rubinowitz, Susan,
"Council
panel told very sick have a lot to $weat about," New York Post,
Apr.2, 1996.)
14.
An Oklahoma neurologist performed a CT scan on a patient suffering
headaches, revealing anabnormality in the brain. The doctor recommended
a magnetic resonance arteriogram, whichrequired a one-night stay in the
hospital. The patient's HMO denied payment on the grounds that thetest
was investigative. The doctor wrote the patient saying, "I still
consider that a magneticresonance arteriogram is medically necessary in
your case..." The HMO wrote to the doctor. "Iconsider your letter to
the member to be significantly inflammatory," the HMO's medical
directorwrote. "You should be aware that a persistent pattern of
pitting the HMO against its members mayplace your relationship with
[the HMO] in jeopardy."
(Trafford,
Abigail, "For Some Doctors Today, Mum's the Word," Washington
Post Health, Mar.12, 1996.)
15.
A 12-year-old girl had to wait half a year for a back operation to
correct severe scoliosis. Thereason: the HMO rejected the parents' bid
to have a specialist perform the procedure, insistinginstead on an
in-network surgeon. After taking six months to determine that no one in
its ownnetwork was capable, the HMO relented.
(Sherman, William,
"Girl waited
6 months for spine surgery," New York Post, Sept.
19, 1995.)
16.
A New York Health Department investigation criticized an HMO and its
doctors for notadmitting a man who failed several cardiograms and who
underwent severe bouts of angina prior tohis heart attack. At one point
during the man's suffering, doctors recommended a dose of Tylenoland
sent him home.
(Sherman,
William, "Pity These Poor Patients," New York Post,
Sept. 20, 1995.)
17.
An 82-year-old woman was forced by her Medicaid managed care plan to
take a genericblood pressure medication instead of the brand name
medication she had taken for years. Shesuffered an allergic reaction
and passed out. Doctors at the emergency room where she was takensaid a
second dose would have been fatal.
(Jouzaitis, Carol,
"Medicaid is
no issue in Tennessee -- it's dead," Chicago Tribune,
Feb. 8, 1996.)
18.
A 2-year-old boy suffered severe seizures and was admitted to the
hospital with a 104.2 fever.The HMO wouldn't pay the $1,124 cost of
overnight hospitalization. The HMO paid the bill afterbeing ordered to
do so during binding arbitration by a state agency.
(Sherman, William,
"Pity These
Poor Patients," New York Post, Sept. 20, 1995.)
19.
A healthy 2-year-old boy was taken to a local hospital after a fall,
with a stick lodged betweenhis upper lip and gums. Once there, health
care personnel repeatedly misdiagnosed the boy'scondition, and, mindful
of the HMO's cost-consciousness, refused to authorize an $800 CT
scan that would have confirmed that he was developing a brain abscess.
As a result of this poortreatment, the boy was left blind and brain
damaged.
(Anagnos
Liapakis, Pamela, "The Malpractice Epidemic: Don't Let the Industry Get
Away with It,"Trial, February 1996.)
20.
A woman who fell on the street and smashed both sides of her jaw was
told by anoral/maxillofacial surgeon that she must undergo surgery to
repair the damage and alleviate the pain.Four other specialists
concurred. The woman's HMO would only pay for repair of half of her
jaw.No explanation was given.
(Sherman, William,
"Managed-care
firm wants half-measure," New York Post, Sept. 21,
1995.)
21.
An HMO refused to let a highly experienced neurosurgion operate on a
30-year-old woman'sspinal cord tumor, insisting that its own,
relatively inexperienced, doctor perform the operation. Thefirst
neurosurgeon even agreed to waive his usual $12,000 fee, given the
life-and-death nature of thetumor, leaving the insurance company
responsible only for hospitalization costs. The HMO stillrefused.
(Burke, Cathy, "Dying
woman
denied doc she needs," New York Post, Sept. 21,
1995.)
22.
A woman had an inner ear operation which required carving down the
bones near her ears. Following the operation, her doctors noticed
draining problems and ordered overnighthospitalization. Her HMO refused
to pay, insisting that all care be provided only on an
out-patient basis.
(Sherman,
William, "Casualties of the System," New York Post,
Sept. 21, 1995.)
23.
A woman whose exploratory surgery for ovarian cancer was approved by
her HMO had thatapproval mysteriously withdrawn after she had already
been prepped for the operation. Not until 30months had passed did she
finally get approval for the procedure. Doctors found and removed
the malignant growth on her ovary.
(Hiltzik, Michael A.
and David
R. Olmos, "A Mixed Diagnosis for HMOs," Los Angeles Times,Aug.
27, 1995.)
24.
When a 23-year-old diabetic asked her California HMO why it wouldn't
cover the cost ofblood-sugar testing supplies, the company's chief
executive told a newspaper reporter that thecompany provides all
benefits required by the state. He suggested that the patient "try and
get a lawpassed requiring the kind of coverage she wants."
(Marsh, Barbara, "A
Diabetic's
Dilemma," Los Angeles Times, Aug. 27, 1995.)
25.
A 48-year-old Arizona woman diagnosed with multiple sclerosis obtained
a referral from herprimary care physician to go to a special treatment
center. She visited the center three times. Her HMO denied her claims
for the visits. A request to cover the cost of her catheters was also
denied.The reason: her primary care doctor did not follow proper
procedure in granting the referral.
(Madrid, David,
"Woman
'punished' for having chronic disease," The Tucson Citizen,
Jan. 9, 1996.)
Cases
26-50.
26. A New York man whose surgery
for varicose veins was OK'd by his HMO was denied the
cost of the necessary preparatory physical. The HMO relented after
being contacted by the state
insurance department.
(Sherman,
William, "Pity These Poor Patients," New York Post,
Sept. 20, 1996.)
27.
A retired New Yorker keeps his prostate cancer in check with monthly
drug injections that cost
his HMO $350 per month. Medicare pays the HMO $550 a month for the
man's care. The $200
profit margin wasn't enough for the HMO, which demanded that the
patient undergo a cheaper and
permanent alternative: castration.
(Sherman,
William, "Ex-New Yorker is told: Get castrated so we can $ave," New
York Post, Sept.
18, 1996.)
School
of the Americas
28. A 16-year-old
boy was sentenced to live a life of perpetual prepubescence because his
parents'
HMO balked at paying $150,000 for three years of hormone injections.
According to HMO
officials, worry over the boy's appearance and height amounted to
"cosmetic" concerns. The HMO
reversed its decision due to mounting public criticism.
(Sherman, William
"Short on Compassion," New York Post, Sept. 19, 1996.)
29.
A woman underwent hand surgery. Her HMO would only let her receive
physical therapy from
a therapist three hours away. After having to wait three months for her
first appointment, the patient
was told at the time of her appointment that the therapist doesn't do
hand therapy.
(Taubman, Bryna,
"Angry readers tell Post they're fed up with the system," New
York Post, Sept.
22, 1995.)
30.
A San Diego paraplegic physician asked for a referral to a
rehabilitation specialist, but her
HMO primary care physician refused. After she developed a severe
pressure wound -- something a
rehab doctor would routinely check for and treat -- her primary care
physician still refused to
authorize a referral. Eventually, the patient had to undergo surgery
and spent a year on her back in a
hospital with round-the-clock nursing care. The HMO's medical director
was quoted as saying
managed care "doesn't adequately meet the needs of the special
patient."
(Marsh, Barbara,
"San Diego in Lead of HMO Revolution," Los Angeles Times,
Aug. 31, 1995.)
31.
A young school teacher was diagnosed with a rare form of cancer. His
HMO had paid for
nearly three years of therapy when doctors finally recommended a stem
cell transplant as the only
treatment that would keep the patient alive. The HMO said it was
"experimental" and denied the
care.
(Haggart, Robert
R., "Teacher Battles Cancer and Bureaucracy," Syracuse
Post-Standard, Jan. 22,
1996.)
A patient was ordered by his
physician to receive three injections of
antibiotic daily for an
indefinite time. The HMO would approve only two, with no explanation.
(Tennessee
Association Home Care, "Postition Statement on TennCare," Sept. 27,
1994.)
33.
A woman was admitted to the hospital suffering abdominal pain. It was
14 hours before HMO
doctors even diagnosed her. In the meantime, the doctors prescribed
painkillers, and did little else.
They eventually had to perform surgery -- 46 hours after her admission
-- to take care of a ruptured
appendix.
(Olmos, David R.,
"Assembly Line Medicine?," Los Angeles Times, Aug.
27, 1995.)
34.
An elderly patient suffered for two months with urinary tract
infections and blood in the urine
before his HMO physician decided to refer him to a urologist. Before he
could be further
diagnosed, however, he was rushed to the hospital after a large
undiagnosed tumor perforated his
large intestine.
(Rosenthal,
Harry, "HMOs not popular with Medicare recipients," Today's
Sunbeam, Jan. 7,
1996.)
35.
A 45-year-old woman was told by her psychiatrist that her anxiety and
depression were so
great that she should be admitted to a special hospital unit for trauma
victims. Her HMO disagreed.
The HMO would only pay for a six-day, non-special-unit, hospital stay
and some outpatient visits.
Upon discharge from her short time in the hospital, her condition
immediately worsened to the point
where she had to be admitted to the hospital and kept for a month.
(Goleman, Daniel,
"Critics Say Managed-Care Savings Are Eroding Mental Care," New
York
Times, Jan. 24, 1996.)
36.
An Oregon physician told his elderly patient that she must have surgery
performed to alleviate
pressure on a nerve in her neck. Her HMO refused to authorize the
operation. The woman sued
and was awarded a $1 million settlement, but not before she completely
lost use of one of her
hands.
(Dietz, Diane,
"HMO:Health pearl or peril?," Statesman-Journal,
Jan. 7, 1996.)
37.
The California legislature, responding to consumer needs, in 1996
established a toll-free phone
bank within the Department of Corporations, the purpose of which is to
handle complaints regarding
HMOs. In its first month the operators logged over 2,000 complaints.
(Lehrer News
Hour, Feb. 6, 1996.)
38.
The Insurance Division of the Oregon Department of Consumer and
Business Services recently
levied a $20,000 civil penalty against a west coast HMO. According to
news reports, an
examination by the state agency "uncovered a consistent pattern of
denying payment of emergency
room claims without a proper investigation."
("Health insurer
fined $20,000," Daily Journal of Commerce, Jan. 11,
1996.)
39.
A woman suffering from a herniated back disc writhed in agony on her
kitchen floor while her
son called 911. The HMO wouldn't pay the cost of the ambulance, saying
her pain, although severe,
wasn't life-threatening, and so wasn't an emergency.
(Hostetter,
George, "She believes HMO rules are aSchool of the Americas pain in the
back," Fresno Bee, Jan. 29, 1996.)
40.
A pregnant woman was rushed to a hospital emergency room, in the throes
of a miscarriage and
bleeding profusely. After a quick exam, the ER staff put in an urgent
call to her HMO with the
question: How do you want us to treat her? It took nearly three hours
for the HMO to call back and
say it wouldn't cover the care because none of its doctors was
available to treat the woman. After
six hours of arguing, the HMO relented.
(Hiltzik, Michael
A., "Emergency Rooms, HMOs Clash Over Treatments and Payments," Los
Angeles Times, Aug. 30, 1995.)
41.
Even after doctors recommended inserting special tubes into a
15-month-old baby's ears to
relieve abnormal pressure and pain, the girl's HMO refused to cover the
cost of the operation. In a
desperate bid, the girl's mother called the local newspaper to
publicize her ordeal. After being
contacted by reporters, HMO officials said they "made a mistake." The
operation was authorized.
(Madrid, David,
"Fighting for health care," The Tucson Citizen,
Jan. 9, 1996.)
42.
In 1995 the Florida Attorney General's office decertified 21 of the
state's 29 Medicaid
managed care plans, citing widespread incidences of poor care.
(Himmelstein,
David U. and Steffie Woolhandler, "U.S. Health Reform: Unkindest Cuts,"
The
Nation, Jan. 22, 1996.)
43.
A Minneapolis woman went to her HMO primary care physician complaining
of headaches and
vomiting. The doctor would not refer her to an imaging center because,
according to news reports,
he was afraid the "HMO would kick him out." Finally, the woman went to
the Mayo Clinic where
an MRI revealed that she had a brain tumor the size of a large fist.
(Schechter,
Heidi, "A Cancer Journal," Minneapolis-St. Paul Magazine,
February 1995.)
44.
A 44-year-old woman complained to her HMO doctor of abdominal pain,
bowel irregularity
and other problems. A routine test called a sigmoidoscopy would have
revealed the problem. The
doctor, though, had had many such recommendations denied by the HMO,
and so didn't bother to
recommend it in this instance. The patient eventually had to have
emergency surgery while on
vacation to remove a tumor that had blocked her colon.
(Hilzenrath,
David S., "Costly Savings: Downside of the New Health Care," Washington
Post, Aug.
7, 1995.)
45.
A New York psychotherapist treating a 10-year-old boy was concerned
about signs of heavy
drug use. She suspected heroin. In fact, an HMO psychiatrist had
prescribed 30-milligram doses of
Prozac for the child, a higher amount than what adults usually receive.
The psychotherpaist
recommended suspending the drug treatment long enough so that she could
talk to the boy, but the
psychiatrist, intent on keeping costs down for the HMO, persuaded the
boy's mother to keep up the
drug use in lieu of therapy.
(Pollack, Ellen
Joan, "Managed Care's Focus On Psychiatric Drugs Alarms Many Doctors," Wall
Street Journal, Dec. 1, 1995.)
46.
Physicians report that HMOs have gag rules limiting their ability to
discuss all viable treatments
with patients. In 1995 one group of doctors in Ohio received a letter
from an HMO that says, "Do
not discuss proposed treatment with [the HMO's] members prior to
receiving authorization." The
letter goes on to forbid doctors to discuss the procedure by which they
get such authorization. An
HMO spokesperson was quoted saying, "It's a very unfortunate statement,
isn't it?"
(Pear, Robert,
"Doctors Say H.M.O.'s Limit What They Can Tell Patients," New
York Times,
Dec. 21, 1995.)
47.
A Florida ratings firm recently completed a national study that
analyzed the
expenditure-to-premium ratio of HMOs. It found that, on average, HMOs
spend 17 percent of
premiums on administrative and marketing costs. (Administrative costs
for Medicare amount to 4
percent). "Too many managers in the HMO industry have their hands in
the cookie jar," the ratings
company's president is reported as saying. "They pay out too much in
salaries, bonuses and other
administrative expenses, but not enough to take care of their members'
health."
(Lavey, John,
"Study measures state HMOs' care expenditures," Nashville
Business Journal, Jan.
12, 1996.)
48.
Patients who fight their HMOs for adequate care are not trying to get
blood from stones.
According to a Salomon Brothers analyst, nine of the biggest publicly
traded HMOs are sitting on
cash reserves of $9.5 billion. Chief executives at the seven largest
HMOs pocketed cash and stock
awards averaging $7 million in 1994.
(Anders, George,
"Money Machines: HMOs Pile Up Billions in Cash, Try to Decide What to
Do
with It," Wall Street Journal, Dec. 21, 1994.)
49.
A former HMO medical reviewer is still haunted by decisions she made to
deny care to
patients. She was quoted in a special report published in U.S. News
& World Report: "If there was
any way at all to claim that something requested was experimental or
nonstandard, we took it. We
looked for ways not to cover treatment," she said.
(Brink, Susan,
"The cancer wars at HMOs," U.S. News & World Report,
Feb. 5, 1996.)
50.
In March, 1995, House Speaker Newt Gingrich called for unprecedented
congressional
investigation of the managed care industry. "We need hearings on
managed care because anytime
you have an accumulation of power comparable to [that in] some of the
communities in which
managed care is now [and] has a very large penetration, you need to
have some kind of government
review of what are the procedures, what are the systems, what are the
terms of employment, what
are some of the conditions of secrecy, etc."
(Chen, Edwin,
"Gingrich Calls for Investigation of Managed Care," Los
Angeles Times, March 29,
1995.)
76.
New York Health Department investigators found out firsthand how
difficult it is for poor
people to get medical care through a Medicaid HMO. After penetrating a
barrier of constantly busy
phones, incorrect numbers, and physicians who were not accepting new
patients or who had left a
particular plan, undercover investigators posing as Medicaid recipients
found that 60 percent of the
obstetricians they called at one HMO could not provide a routine
appointment for a pregnant
woman; 40 percent of the pediatricians called could not fill an
appointment to vaccinate a baby
("Tales From the
HMO Crypt, Part 76," Consumers' Research, Feb.
1996.)
77.
A Michigan man saw his primary care HMO physician for an allergy
problem and was referred
to an allergist. The patient paid his $10 co-payment. Six months later
both doctors were contacting
him complaining that his HMO wouldn't pay up. The HMO said the doctors
sent the bills to the
wrong place, which they denied. The HMO told the enrollee that he
shouldn't be dealing with billing
problems, despite his doctors telling him to handle it. A four-month
frenzy of phone calls and letters
followed. After nearly a year of headaches for the patient and the
doctors, the HMO relented and
paid the claims.
(Jodon, Bob, "The
time the HMO didn't work," Adrian Telegram, Mar. 3,
1996.)
78.
In its own annual report to stockholders last year, one of the largest
HMOs in the nation
reported that an average claim took 86 days to pay in 1994, up from 68
days in 1992. A statistical
analysis of the complaints filed against the same HMO with the New York
State Insurance
Superintendent shows that the average bill for emergency out-of-network
care took 14 months to
pay.
(Fein, Esther B.
and Elisabeth Rosenthal, "Delays by H.M.O. Leaving Patients Haunted by
Bills,"
New York Times, Apr. 1, 1996.)
79.
A woman whose twin sons were born with a severe nervous disorder that
puts them at risk of
heart or lung failure every time they go to sleep was told by her
doctor that home nursing care was
necessary to keep her children alive. The care was denied by her HMO
because the HMO
bureaucrats decided it wasn't "medically necessary." The woman sued and
won, forcing the HMO
to pay for the care.
(Olmos, David R.,
"Twins' Mom Wins Fight Over Home Care," Los Angeles Times,
Mar. 7, 1996.)
80.
A Missouri woman was diagnosed with a malignant breast tumor. Radiation
treatment was
prescribed and successfully eliminated the cancer. The treatment claim
was denied by the woman's
HMO as not medically reasonable. It took the woman two years to
convince the company to pay
the claims.
(Kravetz, Andy,
"Group pushes for single payer health-care system," Columbia
Missourian, Feb.
26, 1996.)
81.
Because of complex HMO rules, a woman suffering severe pelvic pains and
cramps on a
Sunday evening was unable to see her gynecologist until Wednesday
afternoon. Before arriving for
the scheduled examination the doctor's office called to say the HMO
hadn't yet approved the visit.
The woman told the scheduler that, ready or not, she was coming in for
her examination. And she
did. Yet, it had to take three days until she could be told her pain
was caused by an infection in her
uterus and her Fallopian tubes, for which antibiotics were prescribed.
(Smokes, Saundra,
"HMOs: Into what are we getting ourselves?," Syracuse
Herald-American, Feb.
25, 1996.)
82.
A Harvard researcher studying the conditions that make HMOs successful
came to a surprising
conclusion: quality of patient care has no bearing on a company's
success. "One of the plans had a
terrible reputation for quality," the researcher was quoted as saying.
"It had a high level of
grievances and turnover. Yet it was one of the fastest-growing and most
successful HMOs."
(Zaldivar, R.A.,
"Health:cost vs. quality," San Jose Mercury News,
Mar. 31, 1996.)
83.
A woman who had a breast lump biopsied on the advice of her doctor was
refused coverage by
her managed care plan after the report came back benign. Because the
lump was benign, the
managed care organization classified the biopsy as "unnecessary."
(Laster, Leonard,
M.D., "Managed care translates to 'Let the patient beware'," American
Medical
News, Feb. 19, 1996.)
84.
One of Texas's largest medical-malpractice insurers in 1996 asked for a
22.9-percent rate
increase, citing growing losses from rising misdiagnoses among
physicians in HMOs and other
managed care practices. Signifying that that was just the first wave of
such rate hikes, another Texas
carrier in 1996 sought a 32-percent increase, and a large Chicago
company sought a 45-percent rise.
(Bass, Frank,
"Insurer Seeks Rate Rise, Citing HMOs," Dow Jones News Service," Mar.
6, 1996.)
85.
HMO guidelines in use throughout the country recommend denying payment
for the removal of
more than one cataract unless the patient is young and needs both eyes
to work.
(Myerson, Allen
R., "Helping Health Insurers Say No," New York Times,
Mar. 20, 1995.)
86.
The same HMO guidelines provide stroke victims only three days
hospitalization -- even if they
still can't walk following their three inpatient days.
(Myerson, Allen
R., "Helping Health Insurers Say No," New York Times,
Mar. 20, 1995.)
87.
These HMO guidelines consider mastectomies outpatient procedures.
(Myerson, Allen
R., "Helping Health Insurers Say No," New York Times,
Mar. 20, 1995.)
88.
An HMO asked that a woman who suffered a heart attack be moved from her
hospital to one
with which the HMO had a contractual arrangement. The first hospital
said the patient was in no
condition to be moved. She later died in the first hospital. The HMO
would not pay any
hospitalization costs, saying the deceased woman's heart attack was the
result of a pre-existing
condition.
(Sherman,
William, "Casualties of the System," New York Post,
Sept. 21, 1995.)
89.
A man admitted to his wife that he felt an emotional attachment to a
woman who worked in his
office. He was upset by these feelings and scheduled an appointment
with an HMO therapist. The
therapist, fulfilling his role as gatekeeper, nipped the problem in the
bud on the first visit by advising
the patient to leave his wife. The wife, obviously upset with this
advice, scheduled her own
appointment and was told by the therapist, "Your husband wants to be
single, so let him be single."
(Meehl,
Joanne
H., "Managed Marriage," Washington Post, Mar. 26,
1996.)
90.
After getting authorization from her HMO, a New York woman took her
child to a doctor for
the removal of a tick from the child's head, a perfectly routine
medical procedure. Following the
doctor's instructions, the woman brought the child back in a few days
to have the single stitch
removed. The HMO refused to pay for either visit because the second
visit was not pre-authorized.
(Sherman,
William, "Play By The Rules," New York Post, Sept.
19, 1995.)
91.
A large California HMO came under fire in 1996 for twice sending policy
statements to its doctors saying it
is "not recommending nor endorsing routine, universal vaccination" for
chicken pox with a new
FDA-approved vaccine. State law requires HMOs to pay for the
vaccination, but this policy of
non-recommendation effectively reduced the company's financial burden.
The HMO expressed
concern that the vaccine may have side effects. Its decision, however,
contradicted the
recommendations of the American Academy of Pediatrics, the American
Academy of Family
Physicians and the Centers for Disease Control and Prevention's
advisory committee on
immunization practices.
(Green,
Jay, "PacifiCare takes hits over shot," Orange County Register,
Apr. 2, 1996)
92.
In an example of how privacy is being lost in the managed care
environment, a woman seeking
an appointment with a psychiatric therapist for a crisis relating to an
incident of childhood incest was
required by her HMO to first call a toll-free number and speak with a
gatekeeper. The gatekeeper
asked the patient, "Can you tell me how many times you were abused?"
(Riley,
John, "When You Can't Keep a Secret: Insurer's cost-cutters demand your
medical details,"
Long Island Newsday, Apr. 1, 1996.)
93.
An Arizona woman attending college in Washington broke her arm and went
to an emergency
room for treatment. Her parents' HMO said that it would pay for the
initial treatment but that all
follow-up care must be administered by the patient's primary care
physician in Arizona. When the
patient explained that she was not on vacation, but enrolled in an
out-of-state college, she was told
it didn't matter, the HMO would only pay for follow-up treatment in
Arizona.
(Cisak,
Carol J., "Patients at whim of unreasonable HMO rules," Gilbert
Tribune, Mar. 23, 1996.)
94.
A woman slipped in her tub and injured her elbow. At 10:30 p.m. the
woman's mother arrived
and took her to an emergency room for X-rays. The arm was not broken
and the emergency room
doctor gave the patient instructions on how to care for her injury. Her
primary care physician called
her a couple of days later and told her he would not authorize payment
by her HMO because he
hadn't been called before she went to the hospital.
(Fields,
Lillie, "Deciding Who Pays," St. Louis Post-Dispatch,
Apr. 4, 1996.)
95.
A man in Texas called his HMO's toll-free "help line" for a referral
after he had experienced
trouble breathing. No one answered. He went to an emergency room and
was treated. The HMO
refused the $174 cost, saying the problem, which turned out to be
bronchial disease, cannot be
considered an emergency. The HMO relented after a state inquiry was
initiated.
(Sherman,
William, "Pity These Poor Patients," New York Post,
Sept. 20, 1995.)
96.
A 9-year-old girl was diagnosed as having a rare form of kidney cancer.
The girl's pediatrician
recommended that her parents take her to a pediatric specialist for
surgery. The parents' HMO,
however, listed no such specialist. The father and mother made the
decision to go out-of-network to
find a surgeon with a proven track record with this kind of operation.
The HMO called the parents
-- while the girl was still in intensive care -- to tell them that it
would not pay any of the medical bills.
Eleven months later an arbitrator ordered the HMO to pay the hospital
and surgeon bills --
everything but the couple's legal expenses, which by then had amassed
to five figures.
(Letter
to the California Nurses Association, in response to "Patient Watch"
advertisements placed
in 1996 in a number of national and local newspapers; name of writer
available upon request to
CNA.)
97.
A woman with badly infected plantar warts was referred to a
dermatologist by her HMO
physician. The dermatologist's intuition told him that the woman should
see a podiatrist before he
attempted to remove the warts. When he called the primary care
physician to get the referral, the
two doctors didn't discuss medical issues; instead, the primary care
physician asked, "Whose
capitation is this going to come out of -- yours or mine?"
(Greenberg,
Michael, M.D., "Moment of truth leads to escape from capitation
'gulag'," American
Medical News, Mar. 11, 1996.
98.
A man with a complicated liver cancer went to his general practitioner
who took it upon himself
to treat the cancer for three months, all the while the tumors grew and
the patient's calcium count
reached dangerously high levels. The physician at first diagnosed the
cancer as a parathyroid tumor
and said he would have to "read up on it." Finally, he gave up, sending
the patient to an oncologist
who was shocked upon seeing him for the first time. The patient, who
was immediately hospitalized,
said, "I can see no justifiable reason outside of perks and bonuses
from the HMO carrier that [the
primary care doctor] did not send me to a specialist."
(Letter
to California Nurses Association, in response to "Patient Watch"
advertisements placed
in 1996 in a number of national and local newspapers; name of writer
available upon request to
CNA.)
99.
A man had a pinched nerve and needed back surgery. The condition was so
bad that he was
losing the use of his foot and was actually dragging it. Delaying an
operation could cause "serious
damage," said his orthopedic specialist. The patient's health plan,
however, stuck ridgedly to its
guidelines. The doctor was told that the patient's condition had only
persisted for four weeks and
that he had to wait the recommended six weeks. The physician is quoted
as saying that the HMO
"failed to appreciate that the guidelines were designed to be used as
exactly that, i.e., guidelines for
proper, timely and appropriate care. My patient needlessly suffered for
two more weeks."
(Protos,
John, "Ten Things Your HMO Won't Tell You," Smart Money,
March 1996.)
100.
A Florida man took his wife to the emergency room. She had been
suffering from stomach
pain and was perspiring. The HMO told the emergency room doctor that it
wouldn't pay for the visit
and suggested that the patient take antacids and be sent home for the
weekend. The patient's
husband got his wife admitted to the hospital by saying she was covered
under his supplemental
insurance plan, even though she wasn't. Doctors operated and removed a
blockage in her stomach.
(Cohen,
Sarah, "So, what's a little fib between foes, anyway?", St.
Petersburg Times, Apr. 8,
1996.)
Yet
another 25 true horror stories...
Cases
101-125
101.
A 46-year-old woman was rushed to a Detroit emergency room in full
cardiac arrest. Her
husband had called 911 after she collapsed while getting out of a car.
Despite efforts to save her,
she died after 30 minutes at the hospital. After a few months, the
bereaved husband received a call
from the woman's HMO. The company wouldn't pay for the emergency room
visit because the
patient hadn't received prior authorization.
(Henry,
Gregory L., "Emergency Care Under Managed Care: A Fatal Distraction?", Health
Systems Review, April 1996.)
102.
A woman was sent home from the hospital by her managed care company 24
hours after
giving birth. Once home, the mother became alarmed that the baby
wouldn't breastfeed, falling
asleep after only a few minutes of feeding. The mother called a nurse
at the hospital for some
advice, but nothing the nurse said helped. After two days, the managed
care company sent a nurse
to the woman's home. The mother voiced concern over the baby's yellow
skin and eyes, but the
nurse said he was fine. Doubting the nurse's opinion, the mother took
her child to her pediatrician.
Before even crossing the room to examine the baby the doctor said, "Get
him to a hospital." The
jaundice was so bad that there was risk of severe brain damage.
Furthermore, the child was
dehydrated and lost more than a pound because he hadn't eaten properly.
(Gilbert,
Susan, "4 Things You Must Know Before Your Next Health Checkup," Redbook,
January 1996.)
103.
A 32-year-old woman arrived at an emergency room complaining of severe
abdominal pain.
Her physician told her two days earlier that, despite her tubal
ligation, she was pregnant. The
emergency room nurses called the woman's HMO to obtain prior approval
before she was
examined by a doctor. The HMO gatekeeper denied authorization. the
doctor decided to see the
woman anyway and discovered that she had an ectopic pregnancy -- a
life-threatening condition
requiring emergency surgery. The doctor spent the next six months
arguing with the HMO over
who should pay the bill.
(Henry,
Gregory L., "Emergency Care Under Managed Care: A Fatal Distraction?", Health
Systems Review, April 1996.)
104.
A 56-year-old HMO member was rushed to an emergency room with signs of
a dangerous
blood clot in her leg. She was classified by nurses as an urgent case,
but was not seen by a doctor
until four hours later. She died that day. It took three years and
$22,000 of the family's money
before a malpractice claim against the HMO could even get to
arbitration. In a unanimous verdict,
three arbitors found against the HMO.
(McGuire,
Rick, "Cost containment adds to malpractice burden," Medical
Post, Mar. 19, 1996.)
105.
A nurse at a hospital contracted by a managed care company to handle
high-risk pregnancies
did nothing when a woman giving birth suffered a ruptured uterus. The
baby was born a spastic
quadriplegic. The three nurses on duty in the labor/delivery wing had a
total of just six years of
obstetrical nursing experience. The parents sued the hospital for
malpractice; a jury awarded the
parents $98.5 million.
(McGuire,
Rick, "Cost containment adds to malpractice burden," Medical
Post, Mar. 19, 1996)
106.
An executive at one of the largest managed care companies in the nation
was given a $3.9
million salary in 1994 and in 1995 was awarded a $1 billion bonus
following a buyout of his
company by another insurance corporation.
(Auerbach,
Stuart, "Managed Care Backlash," Washington Post,
Jun. 25, 1996.)
107.
A New York man, previously forced to repay $250 for calling an
ambulance, the cost of
which his managed care company denied, at a later date decided to drive
himself to the hospital
although he was having a heart attack.
(Hammersley,
Margaret, "Disadvantaged fare poorly in managed care, panel told," Buffalo
News,
Mar. 28, 1996.)
108.
A San Diego woman's HMO denied surgery for her daughter's disfiguring
red birthmark on
her face. After the woman complained to the California Department of
Corporations, the HMO
approved the procedure as a "goodwill" gesture.
(White
Jeanette, "Unhealthy competition?", Spokane Spokesman-Review,
Mar. 31, 1996.
109.
Paramedics rushed an Oregon man to a nearby emergency room after he
collapsed in a
restaurant with welts all over his body. His managed care company felt
that his ordeal wasn't an
emergency and so denied his claim.
(White
Jeanette, "Unhealthy competition?", Spokane Spokesman-Review,
Mar. 31, 1996.
110.
In November of 1990, a 35-year-old upstate New York man suffering a
burning sensation in
his stomach made an appointment with his HMO physician. The physician
diagnosed peptic ulcer
disease, wrote a prescription for a common antacid, and sent the
patient on his way. After taking
the antacid twice a day for six weeks, the patient returned to the
doctor, still complaining of pain.
The physician wrote out another prescription for the same medicine. The
pain persisted. Five
months later, the doctor ordered abdominal X-rays, and found nothing
unusual. The antacid
treatments continued for two more years. By the fall of 1994, the man
was dead of stomach cancer,
at the age of 40.
(Smith,
Amber, "Misdiagnosed Cancer Kills Local Man," Syracuse
Herald-Journal, Mar. 25,
1996.)
111.
After noticing a small lump in her breast, a 38-year-old woman visited
her HMO gatekeeper
physician. The physician ordered an ultrasound and mammogram. Both
showed negative results.
The physician, however, neglected to tell the patient that the
ultrasound report suggested that a
biopsy needed to be performed to study the suspicious-looking lump more
closely. He also
neglected to tell the patient that under the HMO's capitation policy he
made more money by not
referring her for extra treatments. Only when another mammogram was
performed two years later,
and the lump was found to have grown, was a biopsy finally ordered. By
that time, the tumor was
too large to remove completely by surgery.
(McCall,
Tracy, M.D., "Some HMOs Are Bad News (Is Yours?)," Redbook,
August 1996.)
112.
In Texas, a surgeon performing a hysterectomy discovered that the
patient also had a fibroid
tumor. The woman's physician contacted her HMO to get authorization for
surgery to remove the
tumor, but never heard back from the company. The day before she was
scheduled to go into
surgery, the HMO denied coverage without giving a reason. The woman had
to get ahold of
photographs of the tumor taken during her earlier hysterectomy and hand
deliver them to her
HMO's utility review committee. A week later the HMO authorized the
procedure.
(Spaulding,
Cathy, "Patients, doctors: 'HMOs save money, but at whose expense?", Lewisville
Leader, Aug. 14, 1996.)
113.
A woman who had a three-and-a-half pound pelvic tumor removed was seen
by her HMO's
"concurrent utilization reviewer" two days later, as she was eating her
first post-operative meal in the
hospital. The HMO's employee couldn't see why the patient should stay
in the hospital for five to
seven days, as a number of obstetrical surgeons had recommended. The
HMO employee
telephoned one of the HMO's physicians and together they decided
--without physically examining
the patient -- that she had gotten all the hospital care she needed.
The woman's surgeon refused to
discharge her and had her stay in the hospital for an extra night -- a
cost the HMO wouldn't cover.
(Herbert,
Bob, "When an HMO gets carried away with the rules," New
London Day, Aug. 10,
1996.)
114.
An HMO serving 8,500 of the poorest residents in Syracuse, New York,
reserves the right to
refuse emergency room visits unless patients first call for approval.
Yet, according to a SUNY
Health Science Center study, more than half of the HMO's patients don't
have telephones. Because
of this telephoning policy, the study noted, one Medicaid HMO found
reason to refuse payment to a
downstate New York hospital for five emergency deliveries because the
mothers neglected to
receive prior approval to have babies.
(Smith,
Amber, "Bottom-Line Medicine," Syracuse Herald-American,
Aug. 4, 1996.)
115.
A four-month-old girl underwent surgery to remove a cancerous eye. The
child's doctor
explained that a prosthetic eye would be necessary every six months or
so for the next few years to
prevent the child's head from growing lopsided. Furthermore, the doctor
explained, without the eye,
the girl would be susceptible to chronic infection and discharge. The
HMO refused to pay for more
than one false eye. Only after the doctor sent a letter to the HMO
stating, "I will not be held
medically or legally responsible for the final outcome should this be
denied by you," did the health
plan relent.
(Smith,
Amber, "Baby with rare cancer needs artificial eye; HMO says it won't
pay but does
anyway," Syracuse Herald-American, Aug. 4, 1996.)
116.
A woman who had a giant tumor removed from her sinus region in 1980 was
left with a long
jagged scar down the center of her face. Doctors had put a new nose on
her face, reconstructed
with material taken from her hip. Over the years the patient's skin
tightened, crooking her nose to
the left. In 1994, the patient asked her surgeon to center her nose.
Her HMO called the surgery
"cosmetic" and denied reimbursement. Only after the state insurance
commissioner sent a letter of
inquiry to the HMO asking, "On what basis has [the HMO] determined
reconstructive surgery was
cosmetic in nature?" did the plan reverse itself and authorize payment.
(Smith,
Amber, "HMO ignores law, withholds payment," Syracuse
Herald-American, Aug. 6,
1996.)
117.
The Nebraska mother of an 11-year-old girl was told by her new Medicaid
HMO that her
daughter would no longer be allowed to see the Omaha pediatrician who
treated her rare and
sometimes painful growth disorder. The child's new HMO-approved
pediatrician didn't have the
specialized training needed to treat the disorder or to prescribe the
necessary medication. As a
result, the child suffered her malady for months without her needed
medication.
("Lincoln
woman recounts nightmare in dealing with new plan," Grand
Island Independent, Aug. 5,
1996.)
118.
An 83-year-old woman who underwent brain surgery was sent to a
rehabilitation facility at the
insistence of her HMO after only two days in the hospital. At the
rehabilitation facility she was left in
a wheelchair without restraints. She fell and broke her leg, ending up
in the hospital once again.
After leg surgery, the woman was kept in the hospital for three days,
but the HMO forced her out
to another rehab facility.
(Iverson,
Howard, "An Rx for health care," Beverly Citizen,
Jul. 17, 1996.)
119.
California investigators issued a scorching report damning one of the
state's largest HMOs for
shoddy emergency medical service. A number of cases cited in the report
by the Department of
Corporations indicates that "the plan may be unreasonably denying
coverage for emergency
services." In one case, a patient suffering from acute appendicitis was
taken to a hospital outside the
HMO's system and admitted for emergency surgery. Doctors at the
hospital told the HMO that it
would be risky to transfer the patient, but the health plan refused to
provide coverage at an
out-of-network hospital.
(Kanigel,
Rachele, "Several Kaiser policies get harsh criticism from state," Oakland
Tribune, Aug.
29, 1996.)
120.
An Oregon HMO was recently fined $15,000 by the state Department of
Consumer and
Business Services for improperly denying emergency room claims.
According to the state
investigation report, the HMO had determined whether to pay for
emergency room visits solely by
examining emergency room records. According to the state's report,
these records rarely provide
the information necessary for deciding approval or denial of a claim.
(Hoover,
Erin, "State fines HMO for denial of claims," Portland
Oregonian, Aug. 25, 1996.)
121.
A woman who took her two daughters to her doctor for treatment of strep
throat was told by
an HMO clerk that costs for both the visit and the antibiotic
prescribed by the doctor would be
denied because the bacterial infection was "a pre-existing condition."
(DeCarlo,
Tessa, "Making managed care work for you," Glamour,
September 1996.)
122.
A woman left paralyzed from a pregnancy-related complication has had a
number of
treatments denied by her HMO. Following initial diagnostic tests, the
HMO would not allow further
testing on the patient's brain, saying that a simple visual diagnosis
by a doctor is sufficient to
determine progress. The HMO also turned down occupational therapy
recommended by a
neurologist, and an eye examination prescribed by an ophthalmologist.
(Adams,
Robin, "HMO does provide care, but denies treatment too," Lakeland
Florida Ledger,
Aug. 1, 1996.)
123.
One California managed care organization recently stated that it would
pay for no more than
five hours of epidural pain relief for labor pains. Doctors object,
stating that some labor pains can go
on for more than 20 hours.
(Lagnado,
Lucette, "But Who Will Pay for the High Cost of Relief?", Wall
Street Journal, Aug. 20,
1996.)
124.
An HMO executive was quoted in the Des Moines Business Record, saying,
"We see people
as numbers, not patients. It's easier to make a decision. Just like
Ford, we're a mass-production
medical assembly line, and there is no room for the human equation in
our bottom line. Profits are
king."
(Berko,
Malcolm, "The real story about HMOs," Des Moines Business
Record, Sept. 2, 1996.)
125.
A teen-age California girl receiving periodic blood transfusions to
help prevent stroke and
other problems associated with her sickle-cell anemia, had her
treatments stopped after her mother
was forced to join an HMO. The HMO hematologist said that the
transfusions weren't necessary.
The girl's mother went to two other independent hematologists who both
recommended the
transfusions continue. The HMO wouldn't relent. The girl suffered a
stroke and died.
(Herbert,
Bob, "Death by HMO," Rome, Georgia News-Tribune,
Sept. 1, 1996.)
126.
A pregnant woman was hospitalized after a radiologist told her she had
a placenta previa. Her
HMO doctor disagreed with the radiologist and told the woman everything
was fine, despite her
continual bleeding. Ten days after her due date, the patient hemmoraged
and was hospitalized for an
emergency C-section. After the surgery, the HMO demanded that the woman
be transported to a
hospital 80 miles away. The ambulance came to transport the patients,
but didn't have the
equipment necessary to transport the infant, so attendants gave the
child to the father to hold. Upon
arrival at the hospital, the baby was refused admission, so the father
took the child to his mother's
home, another 40 miles distant. Haggling for eight hours over the
phone, the father finally succeeded
in gaining admission for his child. After a series of misdiagnoses for
spinal meningitis and other
non-existent problems, the hospital finally discharged both the baby
and the mother, telling the
parents that everything was fine. The child is today mentally disabled.
Even two years after their
troubles, the parents were still not able to see their child's medical
records, even after
numerous requests to the HMO.
(Nixon,
Kathy, personal communications via e-mail, Nov. 12, 1996.)
127.
A 34-year-old diabetes patient received a kidney transplant in 1987. In
1994 her body began
to reject the kidney. At the time, her HMO doctor realized she was
having trouble, but it took three
days to complete blood tests to evaluate her kidney function and have
the results sent to a transplant
specialist for review, and another week to secure approval from HMO
officials for the patient to get
drug treatment to stop rejection. By that time, it was too late, and
the patient lost her kidney.
(Perl,
Rebecca, "Left Behind by Managed Care?", The Washington Post,
Dec. 3, 1996.)
128.
In 1994, a former HMO medical reviewer wrote a paper about managed care
for a graduate
course in ethics. Here is an excerpt: "I sat at my desk, contemplating
the paper given to me by the
nurse, who had reminded me, in her dutiful way, that this was a 'very
expensive' case. I knew well
by now what this euphemism meant: You better find a way to deny this.
Medically the case was
clear, with no grounds upon which I could issue a denial based on
necessity... I was left only with
finding a loophole that would justify the denial of payment based on
coverage limitations. That this
man, who I would never know, would fail to get his heart was of less
importance to me at that
moment than the accolades I would get when word spread that I saved the
company several
hundred thousand dollars."
(Anders,
George, Health Against Wealth, Houghton Mifflin,
New York, 1996, p. 53.)
129.
A 40-year-old man suffering from cryoglobulinemia, a blood-plasma
disorder that can damage
internal organs, was told by his new HMO that he could no longer see a
rheumatologist for his
condition. The patient could only go through a primary-care doctor who,
the patient alleged in a
subsequent court case, stymied his efforts to see a specialist. A New
York state jury found the
HMO responsible for the man's deteriorating condition, awarding him a
$1 million verdict.
(Anders,
George, Health Against Wealth, Houghton Mifflin,
New York, 1996, p. 80.)
130.
A doctor treating a child's eye infection prescribed an antibiotic that
can be applied painlessly.
The HMO wouldn't pay for the drug, citing a more painful, but cheaper
alternative. The doctor had
no choice but to relent. He is quoted as saying, "To me it matters a
lot whether a four-year-old is in
pain, but to the HMO it's just money. They don't see the child, and
they don't care."
(Anders,
George, Health Against Wealth, Houghton Mifflin,
New York, 1996, p. 87.)
131.
A 64-year-old Pennsylvania man suffering heart attack symptoms was
driven to the hospital
emergency room by his son-in-law. Doctors confirmed that he was indeed
having a heart attack and
saved his life. The HMO refused to pay the charges of $20,254.90. Why?
The patient didn't get
preauthorization to have a heart attack and went to an out-of-network
hospital. The state public
health program administrator wrote a letter to the HMO, ordering the
company to pay the patient's
bills. In the letter he stated that the public's interest in saving the
patient's life "far outweights Aetna's
limited interest in teaching Mr. Popiden a lesson to use a
participating hospital even in an
emergency."
(Anders,
George, Health Against Wealth, Houghton Mifflin,
New York, 1996, p. 144.)
132. A 1996 survey of Chicago HMOs
found that only three out of 25 plans explicitly told their
members that it was all right to phone 911 in a crisis.
(Anders,
George, Health Against Wealth, Houghton Mifflin,
New York, 1996, p. 148.)
133.
A woman with a high-risk prenancy was ordered hospitalized by her
doctor. The doctor
feared a repeat of the woman's earlier pregnancy when he had to order a
caesarean delivery after
the fetus went into distress at 36 weeks. The woman's HMO denied the
request for hospitalization
for the second pregnancy on the grounds that it wasn't necessary. The
company instead authorized
home nursing visits. When no nurse was on duty at the woman's home, the
fetus went into distress
and died.
(Mariner, Wendy,
"Liability for Managed Care Decisions: The Employee Retirement Income
Security Act (ERISA) and the Uneven Playing Field," American
Journal of Public Health, June
1996.)
134.
A Kansas City man suffered a heart attack. While he was recovering,
several physicians
recommended that he undergo special heart surgery at Barnes Hospital in
St. Louis. The man's
HMO refused to authorize coverage because Barnes Hospital was not in
its service area. The
patient's heart quickly deteriorated and doctors recommended a heart
transplant at Barnes. The
HMO refused. The patient died.
(Mariner, Wendy,
"Liability for Managed Care Decisions: The Employee Retirement Income
Security Act (ERISA) and the Uneven Playing Field," American
Journal of Public Health, June
1996.)
135.
In 1991, a young woman was diagnosed with pulmonary hypertension.
Without a lung
transplant, doctors told her, she would live less than two years.
However, the fact that she had a
mild case of Lupus (an autoimmune disorder) gave the HMO the loophole
it needed to deny
coverage. This denial of life saving care was done by an HMO-appointed
doctor who never saw
the patient, who disregarded the opinion of her primary care physician,
and who never requested a
copy of her medical transcripts. After a local television news program
broadcast the woman's plight,
the HMO relented.
(Cromwell, Mary,
"HMO Denies Lung Transplant, Patient Told to Launch Fundraising
Campaign
for Life Saving Care," Casualty of the Day, California Nurses
Association, Oct. 30, 1996)
136.
A 63-year-old woman noticed a mole on her ankle. Her HMO doctor assured
her it was
nothing and told her not to worry. After the mole changed shape and
color, the woman again
brought it to her doctor's attention. The doctor again dismissed it.
Still, the woman expressed
concern and still the doctor did nothing. The woman requested a new
doctor, a request her HMO
took six months to grant. By that time it was too late -- the "mole," a
malignant melanoma, had
spread. The woman died a year later.
(Bancroft,
Montague, "HMO Ignores Cancerous Mole, Delays Patient Request to Change
Doctors,
Patient Dies," Casualty of the Day, California Nurses Association, Oct.
29, 1996.)
137.
A day-old baby was diagnosed with a rare illness called Erb's Palsy.
The baby's pediatrician
and an orthopedic specialist at the hospital both recommended that the
parents take the baby to a
pediatric physical therapist for consultation and therapy planning. The
parents' HMO turned down
their request for a pediatric referral three times, instead authorizing
a referral to a regular
physical therapist, who confessed to the parents that he had never
heard of Erb's Palsy. The parents
had to go out of network, at their own expense, to get proper care for
their child.
(Carnell, Debra,
"HMO Determines Care is Not Needed," personal account posted at the
WNET
web site, Mar. 24, 1996.)
138.
A man was bleeding internally from a ruptured esophageal varices. He
called his primary
physician to get authorization for an emergency room visit. The nurse
told the man to sit tight, that
the doctor could see him in six days. The man instead decided to go to
the emergency room, where
ER physicians gave him a seven-unit blood infusion.
(Robbins, Don,
personal e-mail communication, Jan. 17, 1997.)
139.
A woman went to her HMO hospital with severe swelling in her right
calf. She was told it was
"just a muscle strain" and was sent home. Eight days later she
returned, still complaining of swelling
and pain. She was given Motrin and sent home. Less than a month later,
the woman suffered a
massive pulmonary embolism that had originated in her right calf.
("HMO Shuns
Diagnostic Test; Patient Nearly Dies of Pulmonary Embolism," Casualty
of the
Day, California Nurses Association, Oct. 29, 1996.)
140.
Doctors diagnosed a six-month-old boy with cerebral palsy. Even though
the boy could not
walk, or even crawl, by his second birthday, the parents' HMO deemed a
wheelchair "medically
unnecessary." Therapy was terminated, and then reinstated only after
the parents underwent a
protracted appeals process.
(Hopper, Leigh,
"HMO users urge attention to complaints," Austin
American-Statesman, Mar.
26, 1996.)
141.
A 3-month-old baby girl was taken by her parents to an HMO pediatrician
with a cough and
fever. The doctor, suspecting Cystic Fibrosis, called the HMO to
request approval for a sweat test,
which costs around $50. When detected early enough, Cystic Fibrosis,
though chronic, is treatable.
The HMO refused to authorize the test. Two weeks later, the girl was
admitted to the hospital with
two collapsed lungs and severe pneumonia. She died a month later.
(Wooldridge,
Jamie, "Infant Dies After HMO Fails to Approve $50 Test," Casualty of
the Day,
California Nurses Association, Oct. 24, 1996.)
142.
A woman with severe abdominal pain was taken to an emergency room where
she sought
admission to the hospital. Her HMO physician diagnosed her over the
phone and had her sent
home, concluding that she had "some sort of virus." A few days later
the patient visited her physician
with obvious signs of jaundice. The doctor put her on antibiotics and
sent her home. Three weeks
later the patient was again in the hospital and, according to her
daughter, was "the color of a
daffodil." An ultrasound test was taken, revealing gallstones. It was
too late. The woman died.
(Meiser, Jana,
personal e-mail communication, Jan. 22, 1997.)
143.
A Maryland man called his HMO, concerned that the plan would not pay
for his newborn
baby's daily plasma transfusions. According to testimony submitted to
the Maryland House of
Delegates, the HMO's gatekeeper told the man that his family would have
to come up with the
$300 a day needed to pay for the transfusions. Not to worry, the
gatekeeper said, as soon as the
family expended its savings, it would qualify for Medicaid.
(Kurtz, Josh,
"Maryland health care reform still under the knife," Montgomery
Gazette, Feb. 28,
1997.)
144.
A woman receiving treatment for cysts on her ovaries was forced by her
husband's employer
to move from their health plan to an HMO. She was told that in order to
receive continued
treatment, she would have to schedule an appointment with her new
primary care physician who
would have to give his authorization. However, her new primary care
physician couldn't see her for
three months, despite warnings from the patient's OB/GYN that the cysts
could grow and rupture
without treatment.
(Saba, Mary
Ellen, personal e-mail message, Feb. 9, 1997.)
145.
In 1992, a senior citizen, enrolled in a Medicare HMO, was diagnosed
with colon and lung
tumors and was scheduled for surgery with a cancer specialist. The
specialist, however, never
showed up for the operation. The HMO allowed a less experienced surgeon
to handle the
procedure. Several months later, the patient was told she still had
cancer in her lung. Her HMO
doctors told her to get her affairs in order, that she only had a
couple of weeks left to live. She
disenrolled from the HMO and sought treatment from a top-notch
oncologist in New York, whom
she credits with saving her life.
(Jouzaitis,
Carol, "More Seniors Turning to HMOs," Chicago Tribune,
Mar. 9, 1997.)
146.
A man hospitalized and dying of AIDS told his family and his doctor
that he wished no
extreme measures be taken to save his life. His only wish was that he
not be taken off a respirator --
he dreaded suffocating to death. Once the man lapsed into a coma the
medical director of his HMO
called a pulmonary specialist at the hospital who coincidentally had
just applied for membership in
the HMO. The medical director pointed out the "Do Not Resusitate" order
written by the patient's
primary care physician and demanded that the patient be taken off the
respirator. Without consulting
the patient's family or physician, the pulmonary specialist
disconnected the respirator. The patient
struggled for breath -- and died of suffocation.
(Swartz, Mimi,
"Not what the doctor ordered," Texas Monthly, March
1995.)
147.
A man suffering a flare-up of an ulcerative colitis condition called
his HMO physician for an
appointment. When he got to the doctor's office, he was told the only
person who could see him
was a physician's assistant. The assistant denied the patient's request
for a referral to a
gastro-entrologist and prescribed cortisone enemas. A week later, the
man's symptoms worsened.
Another physician's assistant prescribed still more enemas. The man's
case worsened still. Finally, a
trip to the emergency room revealed a toxic megacolon. The
gastro-entrologist at the hospital told
the patient, "If only you had seen me sooner." A week later the patient
underwent a colectomy and
J-pouch surgery.
(Peabody, Rodger,
personal e-mail communication, Mar. 28, 1997.)
148.
A Medicare beneficiary in New York City signed up with a Medicare HMO,
attracted by the
lack of a monthly premium. Shortly after, she fell and suffered a
traumatic brain injury. She required
an emergency procedure to drain fluid from her brain. Her doctors
recommended that she go to a
rehabilitation facility for follow-up treatment. Her new HMO refused to
authorize treatment at the
recommended facility, and instead suggested that the patient go to a
skilled-nursing home. But the
HMO eventually decided against that, too. The HMO said she needed only
oral medications and
assistance with daily activities, which it does not pay for.
("Can HMOs help
solve the health-care crisis?" Consumer Reports,
October 1996.)
149.
A mother was told that her newborn baby boy needed a series of
corrective surgeries for a
cardiological problem. The parents' HMO, however, wouldn't authorize
the surgery at the hospital
recommended by the baby's doctors. Instead, it urged the parents to
take their child to a hospital
100 miles away. When the parents balked, the HMO then suggested a
closer hospital, but one with
considerably less experience with the particular surgical procedure the
child required. The parents
decided to leave the HMO and give their child the treatment his doctors
said he needed. However,
due to the HMO's wavering, too much time had elapsed between the time
of the doctors'
recommendations and the surgery. The two-month-old boy died. For months
after his death, the
HMO continued sending the parents letters demanding payment for certain
"deductibles" and other
items.
(Sherman,
William, "Managed-Care Casualties Enough to Make You Sick," New
York Post, Sept.
18, 1995. Included in March 20, 1997 press release from Rep. Charles
Norwood's
Congressional office.)
150.
A 21-year-old South Carolina man received severe head injuries in a car
crash, and remained
semi-comatose after brain surgery. Following his surgery, the man was
able to open his eyes, wiggle
his toes, straighten his legs, and respond to questions. However, his
HMO ruled that he be placed in
a nursing home and denied rehabilitation, in spite of the
recommendation of two physicians that he
was indeed a candidate for rehab.
("Today's
Problems," press release from Rep. Charles Norwood's Congressional
office, Mar. 20,
1997.)
151. A 39-year-old woman had
difficulty getting
psychotherapy after she was physically assaulted in front of her home.
Whenever the woman called her HMO to question its decisions to deny
therapy, the clerk at the other end of the line would repeatedly refer
to her as "a mental patient". The HMO's little strategy worked. "I was
so humiliated. I eventually paid for my own treatment," the woman said.
(Pham, Alex, "HMOs
unveil reform
package," Boston Globe, Mar. 8, 1997.)
152.A
woman on a business trip suddenly experienced a racing heartbeat and
collapsed, losing consciousness. The hotel manager called an ambulance,
which came and took the woman to the hospital. As soon as the woman
came to she called her HMO and received authorization for an emergency
admission. The HMO, however, had second thoughts and later denied the
admission. The HMO first claimed the woman's problem, a panic attack,
was not an emergency. Then the HMO claimed that it never gave
authorization. Finally, the HMO said it lost the patient's ER bill. It
took 18 months for the HMO to pay the bill.
(Morgan,
Peggy
and Sarah Robertson, "Can this medical plan be saved?", Prevention,
April 1997.)
153.
An Arkansas woman suffered a broken neck in a car wreck and was rushed
to the hospital. Her managed care company refused to pay her emergency
room claim because she failed to get preauthorization.
("Too
many
HMOs stint on emergency-room care," USA Today, Apr.
11, 1997.)
154.
A 54-year-old man who had just had prostate surgery was told by his HMO
that he must leave the hospital within 24 hours of his surgery, or it
wouldn't pay a cent. He had to leave the hospital for an empty home
even though he was still bleeding and had to wear a catheter to drain
his bladder. He couldn't even walk.
(Morgan,
Peggy
and Sarah Robertson, "Can this medical plan be saved?", Prevention,
April 1997.)
155.
Before an 11-year-old girl underwent surgery for scoliosis, her surgeon
authorized a procedure whereby the girl donated three pints of her own
blood to serve as a standby supply in case it was needed during the
operation. The operation went by without a hitch -- only one pint of
the girl's blood was needed. The HMO wouldn't pay for the cost of
donating and preparing the other two pints of blood, despite the
surgeon's authorization for the donation.
(DeVita,
Elizabeth, "The HMO Police," American Health,
December 1996.)
156.
A Florida man was diagnosed with prostate cancer after obtaining a free
screening from his local hospital. The man immediately disenrolled from
his HMO whose primary care physicians had ignored symptoms of the
cancer and had refused to send him to a specialist. Earlier this year
the patient filed a class-action lawsuit against the HMO on behalf of
"all Florida Medicare beneficiaries who... were tricked and misled
through a scheme of material omissions into enrolling in and/or joining
(the HMO)."
(Longenecker,
Gayer, "Class-Action Suit Against Humana Based On State Law," Eli's
Medicare Risk Report, Mar. 31, 1997.)
157.
A Virginia man, diagnosed in 1988 with severe depression, began
suffering suicidal thoughts in the fall of 1996. His psychiatrist tried
to have him admitted to a hospital in his home town of Richmond. To the
doctor's surprise, the patient's HMO would only authorize out-patient
shock treatment at a Fairfax, Viginia, hospital -- hours away. The
patient was also told he would have to switch doctors, something most
psychiatric experts believe is dangerous for suicidal patients.
(Gogek,
Jim,
"Mental Illness and Mismanaged Care," The Washington Post,
Apr. 22, 1997.)
158.
A child broke a foot as a result of a fall. The child's parent called
her HMO's medical advice number and was instructed by the advice nurse
to go to an emergency room. The HMO later denied payment of the claim.
("Report
Concerning Kaiser Foundation Health Plan of Texas, Inc.," Texas
Department of Insurance, Mar. 3, 1997.)
159.
An HMO enrollee who was experiencing complications related to insulin
shock was authorized by the HMO advice nurse to seek emergency care.
The HMO later denied the claim due to lack of medical records. The
notes in the HMO files indicated, however, that the medical files had
never been requested. The HMO still denied the claim.
("Report
Concerning Kaiser Foundation Health Plan of Texas, Inc.," Texas
Department of Insurance, Mar. 3, 1997.)
160.
An HMO enrollee experiencing severe headaches and vomiting called the
HMO's medical advice line after discovering that the urgent care center
was closed. The enrollee was instructed to go to an emergency care
facility for treatment. The HMO later denied the claim.
("Report
Concerning Kaiser Foundation Health Plan of Texas, Inc.," Texas
Department of Insurance, Mar. 3, 1997.)
161.
A Texas HMO enrollee experiencing severe stomach cramps was told by a
gatekeeper nurse to go to the emergency room, yet the HMO denied
payment. When the Texas Department of Insurance asked a claims examiner
at the HMO to search for claim data for the enrollee, it was discovered
that the data did in fact reflect that the enrollee had been instructed
by the advice nurse to seek emergency care.
("Report
Concerning Kaiser Foundation Health Plan of Texas, Inc.," Texas
Department of Insurance, Mar. 3, 1997.)
162.
The parent of an 11-year-old child called 911 because the child was
experiencing severe bleeding, dizziness, and weakness. The parent's HMO
denied the claim even though the paramedics who responded to the 911
call wrote letters on behalf of the parent to inform the HMO that
emergency treatment had been necessary.
("Report
Concerning Kaiser Foundation Health Plan of Texas, Inc.," Texas
Department of Insurance, Mar. 3, 1997.)
163.
A woman who was eight months pregnant slipped and fell on her stomach.
Upon experiencing abdominal pains the woman, fearing for the health and
life of her unborn child was rushed to the hospital by her husband.
Their HMO denied the claim.
("Report
Concerning Kaiser Foundation Health Plan of Texas, Inc.," Texas
Department of Insurance, Mar. 3, 1997.)
164.
A child fell off a jungle gym, causing head injuries and severe head
bleeding. The child was taken to the emergency room for treatment and
stitches. The HMO denied payment of the claim.
("Report
Concerning Kaiser Foundation Health Plan of Texas, Inc.," Texas
Department of Insurance, Mar. 3, 1997.)
165.
A man was found by a colleague in a state of disorientation and slurred
speech, and appeared to be fading in and out of consciousness. The man,
who appeared to have overdosed on prescribed medications, was taken to
a hospital for emergency treatment. The man's HMO denied the claim.
("Report
Concerning Kaiser Foundation Health Plan of Texas, Inc.," Texas
Department of Insurance, Mar. 3, 1997.)
166.
A Texas man was diagnosed with brain cancer. According to the state
agency investigating the incident, notes in the patient's file indicate
that approximately one year before brain cancer was diagnosed, symptoms
such as headaches, sweating, dizziness, migraines, double vision, and
decreased visual acuity had been reported by the patient.
("Report
Concerning Kaiser Foundation Health Plan of Texas, Inc.," Texas
Department of Insurance, Mar. 3, 1997.)
167.
An 11-year-old child was taken by his parent to a managed care primary
care physician for sore throat, high fever and vomiting. The physician
diagnosed the symptoms as a stomach virus. The next day, the child's
parent again took the child to the physician because the symptoms were
persisting. According to the parent, the doctor appeared perturbed that
the parent had brought the child back, and instructed that the child be
given fluids. The parent took the child to an out-of-network doctor who
diagnosed tonsillitis.
("Report
Concerning Kaiser Foundation Health Plan of Texas, Inc.," Texas
Department of Insurance, Mar. 3, 1997.)
168.
Social workers and therapists told the mother of a 13-year-old boy that
she should seek inpatient treatment for her son, who was suffering from
severe depression and addiction to illegal drugs. Even a state
magistrate weighed in, ordering the mother to seek admission for her
son who, in the opinion of the judge, needed the security of a
controlled environment in a psychiatric hospital. The mother's managed
care organization, however, had other ideas. It would authorize only
outpatient treatment following a brief 48-hour hospital stay. Less than
three weeks after he was discharged from the hospital, the boy, who had
turned 14 a week earlier, took his mother's car around midnight and
raced down a rain-drenched dirt road at 80 miles an hour. He was killed
when the car spun out of control and slammed into a tree. The boy's
psychologist was quoted saying, "Six years ago he would have been in
the hospital -- absolutely -- for a minimum of 30 days. Children like
Stephen were hospitalized so that they could be contained and so there
was a chance to focus on the problem. It was considered medically
necessary six years ago."
(Boodman,
Sandra G., "Managed Care Comes to Mental Health," Washington
Post, May 6, 1997.)
169.
A Florida man visited his HMO's clinic complaining of abdominal pain.
During visits to the clinic over a two-day period, the man was
diagnosed by three different physicians who each advised a different
medical strategy: fasting, laxatives, and a high fiber diet. Several
days later the patient returned, still complaining of pain. An HMO
surgeon decided to operate for suspected appendicitis. During the
operation, however, no appendicitis was found. The surgeon decided to
remove part of the patient's small intenstine on the belief that the
patient's inflamed-bowel condition was the result of a rare form of
cancer. A pathologist later found the inflammation was due to Crohn's
disease, which normally is treatable by medication. The operation left
the man with chronic bowel problems, including explosive diarrhea four
to six times daily. A jury awarded the patient $750,000 after finding
the HMO guilty of negligence.
("Florida
Jury
Awards Patient $750,000, Finds PCA Clinic Was Negligent In Care," BNA's
Managed Care Reporter, May 7, 1997.)
170.
For more than four years a Virginia man sought treatment for his
daughter's nausea and severe recurring headaches. HMO doctors
prescribed adult-strength narcotic pain medication, but did not consult
a neurological specialist. Finally, in May of 1996, at the request of
the girl's school psychologist, HMO doctors ordered an EEG and MRI,
which revealed a tumor that had invaded over 40 percent of the
patient's brain.
("ERISA
Governs Challenge To HMO Policy Encouraging Physicians To Limit Care," BNA's
Managed Care Reporter, May 14, 1997.)
171.
A woman in Oklahoma tripped and fell, breaking her great right toe. It
was repaired. Two and one half months later after
constantly complaining of pain in her chest and hips it was discovered
that she had also broken five ribs in the fall. Tests indicated that
problems were also occuring in her spine. For the next six months a
doctor "guessing game" started. First the diagnosis was fibromyalgia,
then lupus, and finally rheumatoid arthritis. Three managed care
doctors were involved. Finally, driven by constant pain the patient
went out for a second opinion. The doctor she personally sought out
diagnosed her problem with the use of an MRI, a diagnostic tool not
used by her managed care physicians. She had a herniated and shattered
lumbar disc. But by then it was too late. Despite an operation to
repair her back, the patient is now disabled, incontinent and confined
to a wheelchair.
(Keeling,
C.E., "D. Gazel was denied an MRI for 8 1/2 months. Now she
is disabled," Empower! The Managed Care Patient Advocate,web
site, Oct. 2, 1996.)
172.
Physicians recommended that a 38-year-old Maryland man who had just
come out of a two-month coma remain in a rehabilitation hospital longer
than the maximum allowable stay provided by his HMO. The HMO, however,
would only pay for a less expensive alternative -- a nursing home.
(Pekkanen,
John, "What You Need to Know About HMOs," Reader's Digest,
February 1996.)
173.
An HMO denied home health care services, a covered benefit, to a
multiple sclerosis patient, calling such care "not medically
necessary." The medical reviewer made the decision to deny the care on
the basis of a nurse's "inquiry". According to subsequent court
testimony, the nurse never noted that the patient had problematic bowel
management; had been hospitalized for a massive permanent decubitus;
required twice-a-day wound care; and suffered shortness of breath,
atelectasis, quadriplegia, and osteoporosis that caused fractures and
permanent splintering in both legs. The court , in awarding $24,000 in
damages to the patient, said the HMO acted "whimsically" in denying
care.
("HMO
Lacked Knowledge in Home Care Denial," CCH Home Care
Provider's Guide, May 1997.)
174.
After being hospitalized during a trip for chest pains, a man visited
his primary care physician and discussed his family history and current
symptoms. The doctor said a cardiac referral was unnecessary, even
after the man offered to pay for it himself. The man later died of
heart failure. The U.S. Court of Appeals for the Eighth Circuit
subsequently pointed out that the doctor was rewarded for not making
referrals and was docked fees if he made too many. The court also noted
that had the patient known that his doctor was offered such incentives,
he could have made an informed decision whether to trust his doctor's
recommendation.
("HMO
Doctor
Must Disclose Financial Incentives," CCH Health Law Focus,
May 22, 1997.)
175.
A 63-year-old California man, wheelchair bound, with cerebral palsy,
was diagnosed with prostate cancer. Because of his health, his doctor
advised proton beam radiation rather than x-ray radiation. The man's
HMO denied the treatment on the grounds that it was experimental.
During the subsequent internal appeals process, the patient's physician
testified that the HMO had paid for the treatment in other cases.
Furthermore, the patient showed that the therapy was offered at 13
local medical centers and is covered by Medicare, but that wasn't
enough -- the HMO wouldn't pay for something it unilaterally determined
to be "experimental".
(Quinn,
Jane
Bryant, "On Review, HMOs Deal a Stacked Deck," Chicago
Tribune, Jun. 1, 1997.)
176.
A Pennsylvania woman visited her
primary care
physician's office complaining of chest pain, mild shortness of breath,
and numbness in her shoulders lasting about twenty minutes. Her blood
pressure was in the high normal range. An electrocardiogram revealed an
abnormality. The doctor wanted to monitor the patient with a device
called a Halter Monitor but her HMO wouldn't pay for more tests. Two
weeks later, while driving her car, the woman experienced extreme chest
pain and passed out. She was rushed to the hospital where prolonged
resuscitative efforts were performed. The patient never recovered; she
remained unconscious with cardiac arrest and to this day has not
regained consciousness. The woman suffered irreversible anoxic
encephalopathy, and is expected to remain in a persistent vegitative
state for the rest of her life.
("Elsesser
v.
Hospital of the
Philadelphia College of Osteopathic Medicine," C.A. No. 92-3045, United
States District Court for the Eastern District of Pennsylvania,
September 1992.)
177.
A Tennessee man who
was diagnosed a paranoid schizophrenic was recently placed into the
state's new managed mental health plan, TennCare Partners. After riding
his bicycle to the clinic to get his first shot of the drug that keeps
his disorder in check (his first experience with the new managed care
system) the patient was told that, according to the computer, he was
dead. His shot was refused. Later he was switched to another clinic, 15
miles away. After another switch to a third clinic, the man was told
his records were lost.
(Downing,
Shirley, "Critics Say Managed Care is Failing Mental Patients," Memphis
Commercial Appeal, May 25, 1997.)
178.
A 48-year-old Maryland woman suffering from lipodystrophy, a genetic
disorder causing excessive obesity in the lower extremities was denied
a physician-ordered surgery to remove 40 pounds of fat from her legs in
order to help the woman walk again. The woman's HMO declared that
liposuction surgery is cosmetic in nature and is not a covered
procedure "even if it is due to a medical necessity."
(Auerbach,
Stuart, "Surgery Denied -- Who's to Blame?," Washington Post,
Jun. 3, 1997.)
179.
A 43-year-old Michigan woman told three HMO physicians that she was
worried about her unexplained weight loss: the five-foot, three-inch
woman went down to 98 pounds. The physicians all diagnosed
hypochondria. One doctor even told the patient, "Most women would kill
to have your 'problem'." It took two years before HMO doctors finally
diagnosed the real culprit: multiple sclerosis.
(Eberlein,
Tamara, "The Scariest Health News for Women this Year," Redbook,
June, 1997.)
180.
A doctor recommended a hysterectomy for her 41-year-old patient upon
discovering a grapefruit-size cyst alongside the patient's uterus. The
woman's HMO said no, authorizing instead three to six months of drug
therapy to shrink the cyst. The patient was sent home in pain and in
fear of cancer.
(Goodwin,
Jan,
"Surgery to Go," Good Housekeeping, July 1997.)
181.
A 50-year-old man was told by his physician that he needed a bone
marrow transplant to treat his cancer, with his brother as a match. The
managed care company called it "experimental" and denied coverage for
the expensive operation. After a lengthy battle, the managed care
company backed down and authorized the operation. The man died before
the surgery could occur.
(Morganstein,
Mel, personal e-mail communication, Jun. 13, 1997.)
182.
A man with advanced cancer in his lungs and brain was told by his HMO
that the physician-recommended high-dose chemotherapy he was undergoing
was "experimental" and therefore he would have to bear the cost
himself. The HMO wasn't completely heartless, however. The nurse case
manager graciously offered to get the patient in touch with people who
conduct charity events to raise money for treatment denied by managed
care organizations.
(Herbert,
Bob,
"A Chance to Survive," The New York Times, July 4,
1997.)
183.
A 50-year-old woman complaining of bladder pain and blood in her urine
was seen by five different doctors in her HMO over an eight-month
period. The HMO physicians told her she was suffering symptoms of
menopause and was given estrogen. Finally, the woman saw a urologist
who diagnosed bladder cancer.
(Landers,
Ann,
"Ann Landers," The Washington Post, July 15, 1997.)
184.
After conducting tests, a woman's physician suspected that his patient
had a kidney dysfunction. But the doctor's repeated requests to make a
referral to a urologist were denied by the patient's HMO. It took two
years before the HMO finally allowed the woman to go to a specialist,
at which time it was discovered she was in the later stages of renal
failure. An arbitrator ordered the HMO to pay the woman $1.1 million,
saying the case presents "a compelling picture of the problems and
pitfalls" of managed care."
("California
HMO Must Pay $1.1 Million for 'Unconscionable' Refusals, Delays," BNA's
Medicare Report, July 18, 1997.)
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