Pull The Plug.

• Author: SULLIVAN, KIP
• Position: Need for patients' rights

Why HMO rearm can never really work

IN SUNDAY MORNING, DECEMBER 1, 1996, Joseph K., an 80-year-old Minneapolis man insured by an HMO named Medica, slipped on some ice while feeding birds in his yard and cracked a rib. He died Friday morning, December 6, from what the Hennepin County Examiner's Office described as "cardiopulmonary complications" of his fall. Although Joseph had been getting kidney dialysis for four years, he was a healthy man. He played golf regularly and drove himself anywhere he needed to go. According to two doctors who reviewed Joseph's medical file at my request, Joseph was probably killed by an undetected infection that got out of control.

Joseph's HMO doctors had plenty of time to diagnose him correctly. He was examined immediately after his fall in an emergency room, the fractured rib was detected, and Joseph was told to see his primary care doctor the next day, Monday. But on Monday, Joseph's regular doctor was not available. According to Joseph's records, the substitute doctor merely listened to Joseph's lungs to confirm that they were clear. Although Joseph complained about severe chest pain and weakness in his legs, the doctor did not, according to Joseph's medical records, take Joseph's temperature or his blood pressure. He sent Joseph home with the suggestion that he see his regular doctor "later in the week."

By the time Joseph saw his regular doctor on Thursday, he was in a wheelchair, had signs of a serious infection, and was deteriorating rapidly. He was hoarse, vomiting, suffering from terrible diarrhea that his wife had to clean up because he could not move unassisted, and had a temperature so high he refused to wear a coat in the dead of Minnesota winter on his trip to his doctor's office. Joseph's wife harbored the reasonable expectation that her husband would be hospitalized as soon as his doctor took one look at him.

That did not happen. Joseph was not even sent to a nursing home. Instead, his doctor sent Joseph home with the instructions (as his medical records put it) to "call or return to the office if not improving." When Barb Herold, Joseph's daughter, called her 81-year-old mother to find out how the appointment had gone, her mother was nearly beside herself at the seeming indifference of Joseph's doctors. Barb called Joseph's doctor immediately and asked why he had not been hospitalized. His answer was that Joseph might have "the flu" and just needed rest.

When Barb begged for nursing home care at a minimum, the doctor replied that he would authorize a "nurse evaluator" to go out to Joseph's house the next day, Friday. Why another professional had to make an additional evaluation when the doctor had just seen Joseph was not explained. Joseph died at 6:30 Friday morning, 14 hours after his doctor told Barb that Joseph had the flu. Medica never sent Barb or her mother an apology or an explanation. The Minnesota Department of Health, the agency responsible for regulating HMOs, claims to have investigated Medica in response to a complaint Barb filed with the Department, but refused to tell Barb what it found.

HMO Abuse

The abuse of Joseph K. is only one example of the widespread abuse of patients by HMOs that has generated what the media correctly calls an "HMO backlash." The extent of the abuse is difficult to determine, but there can be little doubt that it has worsened as enrollment in HMOs has risen. A July 1999 survey of physicians by the Kaiser Family Foundation and the Harvard School of Public Health found that 72 percent of physicians thought "HMOs and other managed care plans have ... decreased ... quality of health care for people who are sick." Protecting patients from HMO abuse exploded into a political issue in 1996. That year, a...