"Ronald Helm" <[EMAIL PROTECTED]> writes:
Verdict fires warning shot at managed care
Doctor wins case claiming he was fired for delivering high-quality care
Karen Brandon; Chicago Tribune
SAN DIEGO - These are the things Dr. Thomas Self believes cost him his job:
He spent too much time with his patients.
He ordered too many tests that didn't generate enough profits.
He refused to perform unnecessary surgeries.
In sum, he contends he was fired because he advocated "a higher level of
health care" than his medical group would tolerate in a business
increasingly driven by profits and beholden to contracts with managed care
companies.
This month, a jury agreed, awarding him $1.7 million, finding that his
firing was malicious and that he had been defamed. Another phase of the
trial is scheduled to begin Wednesday to determine whether additional,
punitive damages are warranted.
The verdict is believed to be the first of its kind in the nation, making
Self the only physician to have successfully argued, in effect, that a
medical company's emphasis on the bottom line got in the way of a doctor's
attempts to provide good medical care.
The conclusion has pricked a nerve in the managed care era of medicine. And
Self's case is seen as a sign of growing public unease about whether the
balance between money and medicine has been skewed to the detriment of
patients.
"The message is exceedingly clear: patient care over profits, and medicine
over money," said Miles Zaremski, a Chicago lawyer who is past president of
an American Bar Association medicine and law committee. "This message is
being sent by representatives of the American public, the jury."
Self, a 58-year-old pediatrician who specializes in treating digestive
illnesses, said he believes his situation is distressingly typical, judging
from the congratulatory telegrams, letters and phone calls he has received
in recent days from patients and doctors throughout the nation.
"I think when a patient goes to a physician, he shouldn't feel that he's
going to a businessman first," Self said. "He should be going to a healer,
not someone who's going to look at the bottom line and then adjust the
treatment accordingly."
Self was careful to note he does not oppose managed care, "except where it
begins to control the art and science of medicine." But, he added, "Wherever
managed care has become very powerful, physicians have been under some
constraints about what kind of care they can give to their patients."
Though the verdict's symbolism is evident, its practical ramifications are
not. The case, which grew out of a 5-year-old California law, sets no
national precedent. Moreover, it did not directly target a managed care
organization, aiming instead at the actions of a physicians group
contracting with such businesses.
As a result, health maintenance organization representatives were quick to
suggest the verdict was not applicable to them.
But the jurors' decision comes against a backdrop of considerable change in
public policies concerning managed care organizations.
Self's suit addressed a California law enacted in 1993 precluding medical
groups and managed care organizations from retaliating against physicians
for giving their patients appropriate care.
In recent years, about half the states have enacted similar statutes,
Zaremski said.
Legislation is being considered at both state and national levels to hold
managed care organizations more accountable for the repercussions of their
care, or lack of care.
Texas last year became the first state in the nation to allow health
maintenance organizations to be sued for medical negligence.
And legislation has been introduced in Congress that would change the
federal Employee Retirement Income Security Act, which prohibits people who
get their health care through their employer - the vast majority of
Americans - from bringing some lawsuits against HMOs.
"You know all this is a product of groups of individuals in the electorate
complaining about what's going on," Zaremski said.
Alan Bloom, general counsel of Maxicare Health Plans, a company that runs
HMOs covering some 700,000 patients in seven states, suggested the verdict
had little relevance for HMOs.
"The HMOs don't tell the medical group how to do their business," he said.
"We sell our plan to the patients. We want the patients to get the best
possible care because they are free to leave us each year if they are not
happy."
But Sherry Bahrambeygui, Self's lawyer, called such interpretations far too
narrow.
"That's an oversimplification, a convenient way for managed care proponents
to hide," she said. "Medical groups as a practical matter are agents of
managed care organizations in this day and age.
"The customer is the managed care organization. They're the ones that
control the flow of patients. And if the managed care organization expresses
dissatisfaction with one of the physicians, a medical group could be faced
with a situation where it says either we get this doctor in line or we get
rid of this doctor or we may lose the contract, which is our livelihood."
Self received medical training at the University of Miami, UCLA and Yale
University before moving to San Diego in 1971. He worked with the Children's
Associated Medical Group until 1995, when he was fired.
In the years leading up to his dismissal, Self said the group became more
dependent on managed care referrals. He found that routine tests were
questioned, delayed and sometimes denied.
He also was urged to see more patients, meaning he would have to spend less
time with them. Though he did not offer evidence at his trial that any
patient's health had been harmed, he contended the quality of care
deteriorated.
"It was clear to me that my medical group was putting business before the
care of patients," Self said. "They did not want to risk angering their
referral sources."
After he was dismissed, patients who came to the group were told Self no
longer was practicing medicine and that he had left no forwarding address,
his attorney said. In fact, Self had moved to an office across the street.
The group spread rumors about Self, saying he was lazy, senile and had lost
the nerve to do certain medical procedures that were necessary in his
specialty.
An attorney for the medical group did not return phone calls for comment.
In the spring of 1995, Self's boss received a letter from the head of a
physicians review committee, acting as an agent for an HMO that had
contracts with the doctors group.
Self used a "shotgun" approach to patient evaluations, the letter
complained. He used too many tests. He "still doesn't understand how managed
care works."
In the future, the chairwoman wrote, the committee might be forced to send
all its referrals to another doctor.
A few weeks later, his attorney said, Self was cut out of the budget in his
medical group.
A few weeks later still, he was fired.
April 27, 1998
99 percent of lawyers give the rest a bad name.
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