Stronger oversight of HMOs sought Physician quality panel could impose sanctions

March 05, 1997|By Marcia Myers | Marcia Myers,SUN STAFF

When a Bethesda doctor answered charges of inadequate care last year, he offered a provocative excuse to state regulators. The HMO made me do it, he said.

One of the state's largest and most reputable health maintenance organizations had allowed him only 7 1/2 minutes to examine each patient, frowned on consulting specialists and provided no late-hours access to patient records, the doctor claimed in a letter to the Maryland Board of Physician Quality Assurance.

The board wanted to investigate the accusations but couldn't.

The reason: The state has power only to oversee doctors who treat patients, not the managers who frequently set the life-or-death policies the doctors follow.

A proposal to change all that is being considered today in Annapolis.

A bill that would give the physician quality board expanded powers to investigate and sanction doctors who impose bad medical policy will be considered at a legislative hearing.

The bill, introduced by Sen. Paula C. Hollinger, a Baltimore County Democrat, would give the board authority over physician administrators at hospitals, HMOs, nursing homes and other institutions.

A recent revolution in health care practice makes the legislation urgently necessary, state health care regulators say. From 1989 to 1995, enrollment in HMOs in Maryland rose by 158 percent. And it's still growing.

At the same time, these health maintenance organizations have aggressively pursued cost savings with formal and informal treatment policies that draw growing public criticism.

"Increasingly, doctors are working for organizations where cost is the pre-eminent consideration," said Dr. Israel Weiner of the physician quality board.

Weiner describes numerous cases in which flawed medical policies harmed patients, even though the board found the patients' doctors blameless:

Failure by the chief of obstetrics at a Baltimore hospital to set up adequate monitoring for a woman in labor. A series of doctors working separate shifts cared adequately for the woman, but because an attending physician was not assigned to monitor the case and coordinate their reports, patterns were missed that would have alerted doctors to perform a Caesarean section. The infant died.

An HMO's denial of psychiatric treatment for a psychotic woman, who instead received outpatient care from a psychologist. In a psychotic episode soon after, the woman suffocated her two sons.

Incompetence by the director of a Baltimore methadone clinic where drugs were dispensed inappropriately and in inappropriate amounts. The physician director did not require adequate patient follow-ups, and many of the drugs were later linked to street drug sales.

The loss or destruction of patient files that in many instances have required re-immunizations of children.

In the past, the board has written letters expressing its displeasure to the administrators. But it wants power to do more.

"We want to be able to force some change in the system," said Weiner. The bill would give the board authority to go as far as revoking the medical license of an administrator.

"We're saying, if you make a decision, you're going to be responsible," Hollinger said. "These decisions have to be based on medical standards of care and not just how much money is going to be made."

A similar version of the bill failed to be enacted last year. The new bill is opposed by groups including the Maryland Hospital Association and the Maryland Association of Health Maintenance Organizations, which argue that institutions already set their own strict protocols and can discipline from within when necessary.

"We're saying if it's not broke, don't fix it," said Debra Williams-Garner of the HMO association. "Medical administrators have all practiced at some point. They don't make decisions off the cuff. We feel the system is working. There are protocols and guidelines, appeals and grievance procedures in every plan. I think a lot of the medical industry is feeling the strain of micromanagement as far as legislators are concerned."

The hospital association believes the bill could cause physicians to resist taking on administrative duties for fear of losing their medical license.

"This bill is written so broadly that anyone -- a department head, chief of surgery, on up to higher levels -- could lose their entire license to practice medicine because they've chosen to be a leader in that institution," said Nancy Fiedler of the Maryland Hospital Association.

The only option the state now has in such cases is to take action against the institution itself.

"But nothing happens to the person responsible," said Carol Benner, head of licensing and certification for the Department of Health and Mental Hygiene. "When we have found these kinds of problems, they've been serious. This bill would keep people on their toes."

The state's largest physician group backs the bill. "If you're making decisions about medical necessity, obviously there's medical judgment employed there," said T. Michael Preston, director of the Medical and Chirurgical Faculty of Maryland.

"So much of the conflict that exists between physicians and managed care arises from judgments that are made by managed care organizations and their directors. Frequently, doctors feel they're in the middle, and they're the ones who are accountable for the patient."

Pub Date: 3/05/97

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