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Family Prevails in Long Struggle With HMO : Health care: Insurer was forced to pay for surgery and care of girl whose life-saving surgery occurred outside her medical group.

THE HEALTH CARE REVOLUTION. Remaking Medicine in California. One in a series.

August 28, 1995|DAVID R. OLMOS and MICHAEL A. HILTZIK | TIMES STAFF WRITERS

Some call Harry Christie the "poster boy" of HMO critics, a man whose struggle to get the right medical care for his cancer-stricken daughter embodies the ills of the system. But to HMO supporters, the Woodside, Calif., electronics salesman is the man who broke the rules--and then badgered the system as he looked for relief.

Christie's story shows the obstacles a family can face when it challenges the system. It suggests how technicalities in HMO contracts can affect what treatment is available to a patient.

The struggle began early in 1993, when Harry and Katherine Christie's daughter, Carley, was diagnosed with a Wilms' tumor--a rare childhood kidney cancer requiring surgery.

At the time, the Christies were enrolled in TakeCare, an HMO later acquired by Fountain Valley-based FHP Inc. TakeCare is a "network model" HMO, meaning that it does not directly provide care, but contracts with medical groups and independent doctors.

There lay the Christies' problem, according to Harry Christie and state officials who examined the case.

The Christie family had signed with Palo Alto Medical Foundation, which did not have a pediatric oncologist--a specialist in children's cancers--on its staff. Instead, Palo Alto proposed that the surgery be performed by its urologist, James Bassett, who had never operated on a Wilms' tumor.

But Harry Christie had learned that the National Cancer Institute's protocol for treatment of the condition advised that the surgery be performed by a "multidisciplinary team of cancer specialists."

On their own, the Christies consulted doctors at Stanford University Medical Center, where Stephen Shochat was chief of pediatric surgery--and a nationally known expert on Wilms' tumors. Shochat had a contract with TakeCare and practiced at the same hospital where Bassett planned to do the surgery.

Shochat examined Carley on Jan. 28, 1993, and determined that she needed immediate surgery. But the Palo Alto group refused to approve him as the surgeon--and that meant TakeCare would not pay for the surgery. Shochat performed the operation the next morning.

As Christie had been warned, TakeCare refused to pay Shochat's bills. But what stunned him was that the HMO also refused to pay for Carley's hospitalization and chemotherapy--bills that would have been incurred even had Bassett performed the operation.

TakeCare's position was that once Christie went outside his medical group, the HMO's responsibility ceased. Christie's position--one later adopted by the California Department of Corporations, which regulates HMOs--was that TakeCare was punishing him for violating its rules.

For the next year, Christie battled his health plan. He appealed the refusal through the grievance procedures of both the Palo Alto group and TakeCare.

Then he took the case to binding arbitration--TakeCare's contract barred him from going to court--and won. The arbitrators ordered TakeCare to pay all of Carley's medical bills.

Still, convinced that TakeCare had violated state law by refusing to pay the bills, Christie pressed state regulators to investigate.

This past January, the Department of Corporations announced that it was fining TakeCare $500,000 for "failing to provide appropriate access to quality medical care, putting in jeopardy the life of a young patient." It was the department's first formal enforcement action in 20 years of regulating HMOs.

What disturbed state regulators was how little TakeCare and other HMOs tell members about the services available under their plans. "Once you pick a primary-care physician," said one person familiar with the case, "he can refer you within his medical group, but you don't get access to the [HMO's] web. That's never clearly explained in any document I've ever seen."

The department also determined that TakeCare misled state investigators when it asserted that Bassett had sought counsel in Carley's case from a top Stanford specialist.

FHP, which is contesting the state agency's fine, argues that the Palo Alto group not TakeCare--made all the coverage decisions. And not only was TakeCare "not ultimately responsible" for the actions of Palo Alto Medical Clinic, the HMO told regulators, it "did not ratify [the clinic's] alleged acts or omissions."

Yet in March, 1993, TakeCare had told Harry Christie by letter that it had performed "a careful and thorough evaluation" of Carley's case. "At this time," the letter said, "we must uphold [Palo Alto's] denial" of payment.

Moreover, Gary Mendoza, who heads the Department of Corporations, says he will not tolerate what appears to be buck-passing between the HMOs that collect customers' premium dollars and the medical groups they pay to provide the care.

"The plan can delegate functions, but they can't delegate responsibility," Mendoza said. "They remain accountable for making sure that the health care is provided to the enrollees."

And Carley? After many months of chemotherapy, she is a healthy, active 12-year-old. "To the best of our knowledge," her father says, "she is cured."

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