SIMI VALLEY, CALIF — Simi Valley, Calif. -- The doctor was heading out of the examination room when Dave Ching blocked the door.
"I asked him to stop," recalled the soft-spoken purchasing agent, "and I said: 'I'm not leaving this room until . . . you prescribe some kind of a test -- anything, any test.' "
It was October 1992, nearly three months since Mr. Ching's wife, Joyce, first had visited Dr. Elvin C. Gaines' Simi Valley office seeking treatment for persistent abdominal and pelvic pain and rectal bleeding.
The pain was only getting worse, yet Dr. Gaines -- her doctor through Metropolitan Life's health maintenance organization -- kept turning down the Chings' requests that he refer her to a specialist.
But now, on her third visit, with Mr. Ching in his doorway, the physician ordered a $261 barium enema X-ray exam and, a few days later, sent her to a gastroenterologist.
The diagnosis was devastating. Mrs. Ching -- a health-conscious mother of a 3-year-old son -- had colon cancer. Twenty months and seven operations later, she was dead at age 34.
Her husband contends it was greed that killed Joyce Ching.
In a malpractice suit scheduled for trial this summer, he alleges the financial incentives in their contracts with the HMO prompted his wife's doctors to place their interests ahead of hers.
HMOs have more than 1.5 million subscribers in Maryland and about 55 million nationwide. As HMO membership soars, legal experts say the case is among the first to address directly the issue of HMO payment practices and their effects on the doctors who deliver care.
At issue: Are "gatekeeper" physicians in managed care systems withholding treatment because providing it takes money from their pockets? Are the doctors' best judgments being colored by shifting financial incentives? Or do the hard realities of medicine today simply give distraught families new openings to second-guess doctors' care?
Reacting to the cost-cutting efforts of HMOs, more than half the states have passed laws restricting their money-saving methods. The Maryland General Assembly recently enacted jumped to the forefront of the trend recently by enacting three bills that protect patients' freedom to choose their doctors, allow women who have given birth to stay in the hospital at least 48 hours and toughen the requirement that HMOs pay for hospital emergency-room care for subscribers.
Gov. Parris N. Glendening has not signed any of the bills into law.
Meanwhile, two doctors in the California case, Dr. Gaines and Dr. Daniel Engeberg, who also treated Mrs. Ching and is a defendant in the Ventura County Superior Court suit, deny any wrongdoing.
"These are caring people who care about their patients," says Michael D. Gonzales, the physicians' lawyer. The doctors contend they were doing what primary care physicians are paid to do in managed care settings: coordinate the patient's care and provide whatever treatment is appropriate. They didn't send Mrs. Ching to a specialist or order extra tests sooner because -- given her symptoms, age and medical history -- they believed it was unlikely she had cancer, according to Mr. Gonzales and court papers.
"Doctors aren't perfect, and sometimes their best efforts prove wrong," the attorney says.
The lawsuit alleges that the HMO industry's preferred system for paying doctors -- known as "capitation" -- provided a strong incentive for Dr. Gaines and Dr. Engeberg "not to provide necessary medical care in order to further their own personal financial interests."
Under capitation agreements, a doctor or hospital agrees to accept a fixed monthly fee per patient from an HMO, no matter how many services that patient receives. HMO critics worry that such financial arrangements are influencing even some ethically minded doctors to do less, not more, in medical situations where the course of treatment is not clear-cut. Lawyers anticipate a flood of suits like Mr. Ching's as HMO membership continues to climb.
The Ching case comes amid a growing clamor about HMOs.
Proponents tout the plans as promoting preventive care while reining in runaway health care costs. Many employers have steered workers into HMOs by eliminating other types of health plans or requiring workers to pay a lot more to join non-HMO plans. The Chings, for example, chose MetLife's HMO over less restrictive plans offered by Mr. Ching's employer because it was cheaper.
But many physicians, nurses and consumer advocates say some HMOs are putting profits before patients.
In Washington, House Speaker Newt Gingrich, Republican of Georgia, has called for a congressional investigation into the practices of the managed care industry. The Justice Department recently appointed a task force to look into possible abuses in managed care involving the denial of necessary services.
The suspicions reflected in those inquiries drive to the very heart of health care reform.
