Patients Caught in Dispute Between HMO, Hospitals

Christian was born four months prematurely, on March 26, and released from a Van Nuys hospital 55 days later. As a child of a mother on Medi-Cal, which serves the state's poor and disabled, Christian was referred to a nearby pediatrician. Christian got good care with his new doctor, Cabrera said, but earlier this month Cabrera was told that the doctor no longer could see Christian.

"My heart sank; I didn't know where to go," said Cabrera, 24.

Cabrera's problem wasn't that the pediatrician, Dr. Pejman Salimpour, did not want to see her son. Rather, Health Net Inc., the insurance company through which Christian receives Medi-Cal coverage, this month halted all new Medi-Cal enrollment at 10 hospitals and about 20 doctors' groups owned by or affiliated with Tenet Healthcare Corp., the state's largest hospital operator.

Health Net took the action because it has been locked in a protracted contract battle with Tenet over hospital reimbursement rates. Their yearlong dispute reflects the heightened tensions between hospitals and health plans as they try to preserve profits and gain market leverage at a time when health insurance premiums are soaring. Medi-Cal has been a growing and important business for both Health Net and Tenet as well as some other HMOs and hospital companies.

Just how many new Medi-Cal enrollees have been inconvenienced or more seriously affected by Health Net's freeze is unclear. Regulators at the California Department of Managed Health Care, which oversees HMOs, said they were looking into the matter but so far have not received complaints from Medi-Cal members.

Officials at Health Net, which reported more than 577,000 Medi-Cal members at the end of last year, said they took the action to reduce the risk of patient disruption if negotiations broke down and resulted in termination of contracts.

But health professionals and consumer advocates say that whatever the intent, some patients such as Christian are getting caught in the middle of two health-care industry giants.

Christian's case illustrates that Tenet and Health Net "are playing hardball with each other, thinking they are not harming patients, when in fact they are," said Lucien Wulsin, director of the Insure the Uninsured Project, a nonprofit group in Santa Monica.