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The Hmo Dilemma
Nutrition Health Review, Winter, 1997 by R.J. Tuleya
Can patients depend on their Health Maintenance Organization to provide adequate health care when they need it? Some Americans are finding out a frightening answer.
Ron Henderson felt something was wrong with his health. A pain spreading from his chest throughout his arms led him to question the condition of his heart and to seek medical attention.
Medical files reveal he demonstrated several of the warning signs for a potential heart attack -- an irregular EKG and a previous heart attack. Yet, doctors dismissed his symptoms, attributing them to a hiatal hernia, and prevented him from seeing a specialist.
In 1995, he died of a heart attack.
"It was terrible. It was an awful ordeal to go through," Irene Henderson told Nightline interviewer Valeri Williams on an episode airing last year. "This wasn't a sudden death. This came on for five and a half weeks. [My husband] asked repeatedly for help from the doctor and it wasn't given."
Jim Morgan, a preacher, died of a heart attack under similar conditions. His medical file reveals he also had an irregular EKG, as well as high blood pressure and high cholesterol. His symptoms were diagnosed as sore ribs. No one ever referred him to a specialist.
Schoolteacher Cynthia Confer died when her aorta ruptured. Again, her medical files state all the warning signs, including "a potentially dangerous heart condition from a dilated or enlarged aorta," Williams reported. Confer was not referred to a specialist because she was diagnosed with bronchitis.
"They had all kinds of opportunities to prevent her from dying, and what she died of is as simple as having appendicitis," said Confer's father, Luther Wallace, to Nightline.
Each of these stories has two things in common: all three patients died in Dallas and all three were members of the same health maintenance organization -- Kaiser Permanente.
Several health maintenance organizations (HMO) around the country, have been under public scrutiny in the last few years because of similar incidents. Kaiser Permanente is the oldest, largest, and richest HMO in the United States. It operates in 17 states, and in 1997, Kaiser was rated, by U.S. News and World Report as one if the top HMOs in 12 of those states. And the company's sights were aimed even higher. In Texas in 1993, Kaiser misdiagnosed nine heart attacks. The HMO successfully solved the problem and reduced the number of misdiagnosed heart attacks to one.
Events have taken a dramatic turn for the worse for the company in the last two years.
Kaiser's practices were investigated three times in Texas and California, and they paid $1 million in Texas to keep their license after state medical officials found Kaiser refused to compensate patients after emergency room visits.
"You trust your doctor. Someone that you can always trust is your doctor," said Brigette Morgan, Jim Morgan's daughter, to Nightline, "and you cannot trust Kaiser."
Says Irene Henderson, "The thought that a man's life was wasted and no one knew or cared about it. They need to start caring about these patients more than the bottom dollar."
The Hendersons, Confers and Morgans all filed suits against Kaiser Permanente stating the HMO cared more about its earnings than helping its patients.
Matters were made much worse for Kaiser during its special settlement trial with the Hendersons when the prosecution presented the HMO's associate medical director, Dr. John Vogt, delivering a speech on cutting costs at an HMO industry conference in 1995.
"The first thing that ever comes out of a Kaiser CEO now is what's the bottom line," Vogt said on a videotape of his speech. "Anytime you have to balance the budget, how do you do it? You cut utilization, drop referral rates, and drop your hospitalization."
Vogt continues, discussing Kaiser Permanente's urgent care centers "We basically said to the doctors, `If you value your job, you won't say anything about hospitalization.' All you'll say is, `I think you need further evaluation and Dr. Shmoe is going to come in and talk with you."
Dr. William Gillespie is president of Kaiser Permanente Texas. He said Vogt's speech was full of exaggerations, jokes and untruths, but one year after Kaiser Permanente reduced its number of misdiagnosed heart attacks to one, the company deemed its new system not cost effective.
"The reason we're revising that protocol now is because our utilization exploded" Vogt said. "The cost of dropping it to only one missed heart attack was tripling our hospital days."
Gillespie argues incorrect diagnoses are more expensive than getting it right the first time. "We fail to give an immunization to a child or we fail to diagnose a patient with cancer, what happens? They come back, they're sicker, they demand more care, they demand more treatment, they demand more attention," he said to Forrest Sawyer. "Their problems are graver for them and it's more expensive. It doesn't make sense to avoid giving care.
"People get sick in hospitals. People die in hospitals from the medication and treatment errors that occur there," Gillespie said. "So we' re going to be looking for every opportunity we can find to improve quality because that's the best and most effective way of taking care of our patients and taking care of the bottom line.
Nightline reported Kaiser Permanente lost nearly $270 million in 1997. In the Henderson case, the victim's family settled out of court for $5.3 million. Jurors said afterward they unanimously agreed Kaiser's conduct was negligent and would have awarded the Hendersons significantly more.
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