SIMI VALLEY — 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 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 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 Dave 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. Joyce--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 that it was greed that killed Joyce Ching.
In a malpractice suit scheduled for trial this summer, he alleges that the financial incentives in their contracts with the HMO prompted his wife's doctors to place their interests ahead of hers.
As HMO membership soars nationwide--California has 12 million members--legal experts say the case is among the first to directly address 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 doctors' 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?
Gaines and Dr. Daniel Engeberg, who also treated Ching and is a defendant in the Ventura County Superior Court lawsuit, deny any wrongdoing.
"These are caring people who care about their patients," said Michael D. Gonzales, the physicians' Los Angeles lawyer. The accusation that greed played a role in their decisions about Ching's medical care, Gonzales said, is "an ugly allegation with no facts to support it."
The doctors contend that 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 did not send Ching to a specialist or order extra tests sooner because--given her symptoms, age and medical history--they believed it was unlikely that she had cancer, according to Gonzales and court papers.
"Doctors aren't perfect, and sometimes their best efforts prove wrong," the attorney said.
The lawsuit alleges that the HMO industry's preferred system for paying doctors--known as "capitation"--provided a strong incentive for Gaines and 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 or how few services that patient receives. The doctor gets paid the same for a healthy young patient who visits the office once a year for a sore throat as for a very sick patient who requires lots of care.
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 lawsuits like Ching's as HMO membership--already 50 million nationwide--continues to climb.
"We are entering a new era with respect to managed care and the responsibilities" of doctors and other providers, said Michael Zellers, a Los Angeles lawyer. "We've seen an increase in these types of cases, and we will continue to see them in California and across the country."
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 chose MetLife's HMO over less restrictive plans offered by Dave's employer because it was a lot cheaper.
But many physicians, nurses and consumer advocates say some HMOs are putting profits before the needs of patients.
In Washington, House Speaker Newt Gingrich 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.
Many HMOs and other managed care plans are designed to hold down costs by discouraging unnecessary use of specialists and surgical procedures.