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Managing Managed Care
By: Thomas V. O'Hagan, Esq.*
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Managed care is becoming ever more common. This environment
presents new challenges in avoiding risks, some of which are illustrated
in a tragic malpractice case I recently began defending.
As is common, the HMO in my case merely markets its plan. It
provides care through contracts with medical groups, who hire
some physicians and contract with others. The patient in my
case was a young woman admitted to a community hospital contracting
with the HMO. Physicians appropriately and quickly diagnosed a
rare disease. The prognosis was good, but the patient urgently
needed treatment requiring equipment and facilities not generally
available at the time outside of major hospitals. Physicians therefore
sought to transfer the patient to an appropriate facility.
Unfortunately, a delay of several days intervened between the
recognition of the patient's needs and the transfer. The patient
died within hours of transfer, before treatment.
Investigation has suggested several reasons why the delay may
have occurred. The specialist, who handled the transfer issue,
wanted the patient transferred to a major facility where he had
privileges, but which had no contract with the HMO. The HMO wanted
the patient transferred to a facility which had a contract. Perhaps
the transfer approval came too slowly because it was first requested
late on a Friday, and weekend staffing was slow. Perhaps there
was some confusion over whose approval was required for the transfer,
as the specialist was uncertain of the demarcation between the
authority of the HMO and the contracting medical group. Perhaps
the approval was delayed because HMO had difficulty understanding
the nature and import of the request, given the rare disease and
unusual treatment involved (which was considered experimental
not long before this case).
Several lessons may be drawn to avoid harm to the patient and
malpractice risk.
1. Insist on knowing whose approval is required for what.
Patients in urgent need of care may not be able to wait for
multiple calls trying to determine what approval is required.
An HMO may not be reliable in pointing you to the correct person
on the first call. It may even be necessary to educate the right
person that they do, indeed, have responsibility for giving you
the approval you need.
2. Communicate with the patient, and perhaps the patient's
family in appropriate cases. The family in my example had
no idea what the physicians were doing to arrange the transfer.
The physicians may have avoided being named if the family had
been told clearly that the lack of approval came despite diligent
efforts of the physicians. Educating them that the receiving hospital
would not accept the patient without the necessary approval might
also have helped (they believed the physicians could have transferred
the patient any time, but needed approval to be paid). The patient
or family may also become your allies in obtaining approval for
appropriate treatment. This communication with the patient or
family should be documented in the patient's chart.
3. Advise HMOs appropriately of urgency. Don't hesitate
to let the administrator know if your patient is in pain, or if
delay could threaten life or limb. Crying "wolf" too often may
be harmful, in the long run.
4. Enlist other physicians on the case to help you. The
specialist in my case probably had little contact with the HMO,
while the attending physician's practice was dominated by patients
from the HMO. Yet, the specialist apparently did not seek the
help of the attending physician in dealing with the HMO.
5. Chart events carefully. The chart in my case fails
to reflect who was contacted for transfer approval, what they
were asked for or told, or when the first calls took place.
6. Follow the appeals process and be the patient's advocate.
A managed care organization's mere denial of authorization for
a procedure, test, or treatment does not mean that your job is
done. Know and use the HMO's appeals process if your medical recommendations
are not taken. Be the patient's advocate and get credit for this
advocacy in the chart and in the patient/family's mind. Document
in the chart and copy the patient/family with any appropriate
correspondence regarding the appeal. Making and documenting your
medical recommendation is not only good patient advocacy but is
good medical practice in the managed care environment.
Managed care presents different challenges, but not necessarily
more malpractice risk. Physicians in a managed care environment
may be called upon more to act as patient advocates, even to make
the system work in spite of itself. Patients and physicians can
both benefit because good loss prevention efforts are good medical
practice.
| *Thomas O'Hagan, Esq. is with the law firm Thomas O'Hagan & Associates in Glendale, CA. He has focused on advising and defending physicians in professional liability matters for over twelve years. |
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