Confessions of an HMO Medical Reviewer- A MUST READ

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From: byrd45 (Original Message) Sent: 6/25/2005 10:25 AM
CONFESSIONS OF AN HMO MEDICAL REVIEWER A MUST READ!!!!!


"My clinical goal was to avoid payment. The outcome was a death sentence."
Charges that health maintenance organizations put profits before patients have dogged the managed care industry in recent years. Consumer groups make many of the accusations, but some of the most disturbing reports have come from former managed care insiders like Kentucky physician Linda Peeno (pictured below). She testified last spring before a California assembly committee that she had caused a California man's death by denying him a heart transplant, a refusal that saved her HMO half a million dollars.

"Everyone was thrilled that I denied that coverage," she told reporters in Sacramento. "If I had approved [the transplant], I would have been gone the next day."

Peeno was in Sacramento to testify in favor of bill AB 794, sponsored by Representative Liz Figueroa, which would require any California physician authorized to deny health care to examine the patient before issuing a denial. As a former medical director or medical reviewer of three HMOs, Peeno says she saw enough cases to know it's dangerous for physicians to decide whether to allow treatment for unknown patients in faraway states. (The bill, passed by the California assembly, was vetoed by governor Pete Wilson in October.) The following is an excerpt from Peeno's testimony.

"Good afternoon.

My name is Linda Peeno. I am a physician. I've come here today to tell you how I, as a physician, reached the heights of modern medicine. Exactly one decade ago my office was on the 23rd floor of a marble building in Louisville, Kentucky. My patient was a piece of computer paper less than half full. My patient's history included a couple of lines of information about a medical condition, and many more about coverage and market data--all passed to me through persons with little or no medical training.

The physician's exam that I did involved a quick assessment that this was an authorization for an expensive service made worse by its occurrence at a hospital with whom we did not have a contract. My clinical goal was to figure out how to avoid payment. And my diagnosis ultimately was a denial. And the outcome was that a man in California--whom I never saw or touched, much less examined--faced a death sentence.

Once I stamped "Denial" on that man's form, his life's end was as certain as if I had pulled a plug on his ventilator. And if I knew his name, it was only for a fleeting second: I remember the details only because of the accolades it brought me from my employer. This event dramatically represents what I came to do as a company doctor.

Eventually I made many more decisions, some of which, I am equally certain, caused additional pain, suffering, even death for other patients. Hardly the work, I believe, of a physician. All of my positions shared a simple goal: I used my medical expertise for the financial benefit of the company whose name appeared on my check. In doing so, I soon realized that I was making decisions that endangered patients.

Under this sham process, I acted like a doctor, but I was not. For I was making medical decisions without ever having complete or accurate information, in areas of medicine about which I knew nothing, with no monitoring or follow-up on outcomes and with no responsibility or accountability for my medical decisions. Although I repeatedly was told that I was not denying care, I was only denying payment, that rationalization did not comfort me.

It is important that I emphasize that I am not anti managed care. However, we do not need a system in which the patients can be put at risk by the distant and dehumanized actions of physicians and other health care employees with [conflicts of interest].

If care is to be limited or denied, it should be done only by a physician who is licensed in the state of the practice, who gathers his or her own information through a thorough hands-on history and physical examination of the patient, who can make decisions in the best interest of the patient without any divided allegiances, and who can inform the patient directly of those decisions--especially when it is a denial. The very practice of medicine is at stake. I urge you to support this bill in order to keep the art of medicine at the personal level of patients--the ones who bear its life-and-death consequences.

[Hippocrates 11(12): 88, 1997. 1997 Time Publishing Ventures Inc.] i

submitted by Al

Note from Keith, A very Brave Woman indeed.