Accountability for managed care HMO loophole: Medical directors set treatment standards but can't be disciplined.

March 27, 1997

A PHYSICIAN serving as the medical director of a managed care company has vast power over patients. Does your primary care physician think you need gall bladder surgery? You better hope the medical director agrees.

Despite all this power, there is no way to hold these physicians accountable for their professional judgments. And unless the House Environmental Matters Committee agrees to consider a bill passed by the Senate earlier this week, that egregious loophole in Maryland law will remain in place.

As more Marylanders are learning, physicians working for managed care groups are under treatment constraints. Their judgments about adequate care often take second place to decisions by the group's medical director, a licensed physician who does not directly treat patients but decides what treatment doctors in the organization should provide.

The physicians who actually treat patients can be held accountable for their decisions when things go wrong. They can be disciplined by a group of their peers, through the state's Board of Physician Quality Assurance. That doesn't hold true for the physicians who tell them what they can and cannot do. Because of a loophole in laws written before HMOs became a big factor in health care, medical directors of managed care organizations are exempt from any professional oversight.

That's unfair to doctors who report to the medical directors and, most of all, to Marylanders whose health care depends on the decisions of a physician held accountable for bottom-line financial results, but not for medical judgments. What other license, whether a driver's license or a professional license, is issued without any further accountability to the state?

The Senate bill contains modifications that make it more palatable than a similar measure rejected by the House committee. It exempts the medical directors of hospitals, provided that treatment protocols have been approved by the hospital's staff. It also provides that a medical director facing disciplinary action would be evaluated by a panel of peers -- medical directors of similar organizations.

These provisions provide safeguards against abuse, while closing a loophole that undermines confidence in managed care.

Pub Date: 3/27/97

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