Q: I belong to an HMO. I have heard about "gag rules" that prevent doctors in HMOs from telling their patients about certain expensive treatment options. I've always believed my doctor had my best interests at heart, so what is this all about?
A: "HMO patients must learn to take care of themselves," said Dr. Ron Bronow, a Los Angeles dermatologist and past president of Physicians Who Care, a patient advocacy organization with about 3,500 physician members nationwide.
Bronow said that when physicians depend on income from an HMO, a conflict of interest between doctor and patient is created. Physicians must toe the company line or risk their livelihoods, he said.
The risk of this is greatest with doctors who are paid under capitation (a set fee per patient paid to the doctor whether or not he sees the patient).
Dr. John Hinton, senior medical director at ChoiceCare (which does not pay its doctors on the basis of capitation), said this risk has diminished as managed care has placed more emphasis on accountability. "Even health plans that are capitated now use underutilization reviews to find doctors who are working the system," he said.
Bronow believes the threat of lost income is real because even though "gag rules" are not longer permissible, most HMOs can dismiss doctors without cause, rendering the lifting of gag rules meaningless. He said HMOs also reward doctors who keep their costs in line -- for example, by limiting referrals or tests -- with a year-end bonus.
As a result, patients are sometimes not offered the care they need, Bronow said.
"HMOs use silent rationing. They use less costly and less effective methods of treatment. The patient will never know (because the doctor may not tell the patient about all the options)," Bronow said. He said doctors go along with this to avoid being "booted out of the HMO."
He said another problem is that HMOs, in an effort to cut expenses, often contract with low-cost providers for medical services, such as lab tests, which can lead to inaccurate diagnoses.
Bronow said that, contrary to popular belief, even when grave medical errors are made, most patients don't sue their doctors, thus giving up any legal remedy they may have.
"They don't know how to sue or they consider a lawyer too expensive," Bronow said. He said his organization provides legal help to people who have been injured as a result of medical treatment that has been selected on the basis of cost-savings rather then efficacy.
Does this problem exist in our area? Leah Obial Gates, who managed her father's medical office until his recent retirement, said it does. She said she has seen practices similar to those described by Bronow. In addition, she said, "The (managed care) insurer dictates how much time doctors can spend with patients. They tell the doctor which specialist they may refer to."
ChoiceCare's Hinton said the HMO-physician relationship is beneficial to the patient. "It allows the primary care physician to guide the patient through the health care maze," he said, which assures that consumers get good cost-effective care.
Bronow offered these suggestions to HMO patients:
1.) Be suspicious, especially if your doctor is hesitant to discuss option with you.
2.) Ask your doctor outright, "Are you getting paid more money for not treating me?"
3.) Ask for the name of the laboratory and pathologist who will be doing your medical tests. Call the lab to research the level of the technician's training.
4.) Get a second opinion from a doctor who is outside the HMO even if you must pay for it yourself.
5.)Use your HMO's formal complaint process if care is denied. At the same time, call your state's department of insurance and your state legislator to report the problem.
Hinton adds yet another tip: Ask you doctor, "What would you do if this was a e member of your family?"
A new book offers further insight into the HMO-physician-patient relationship: "The Insider's Guide to HMOs," by Dr. Alan J. Steinberg, is published by Penguin Books. Physicians Who Care publishes a free brochure, "Are You Thinking of Joining and HMO?" To get a copy, write 10615 Perrin Beitel, Suite 201, San Antonio, Texas 78217. Patients who need help with HMO-related problems may call the organizations' hotline (1-800-800-5154) and leave a voice message. PWC will respond by mail.