HMO Must Pay $28M For Delaying MRI That Could Have Saved Cancer Patient’s Leg

[KamaAina]

http://consumerist.com/2015/03/27/hmo-must-pay-28m-for-delaying-mri-that-could-have-saved-cancer-patients-leg/

Back in 2009, a then 17-year-old woman in California visited a Kaiser Permanente office because she was experiencing strange back pain. In the months that followed, she and her mother say they repeatedly requested an MRI but Kaiser doctors would only tell her to lose weight or get acupuncture treatments. All the while, a cancerous tumor was growing that would eventually result in the surgical removal of her right leg, and parts of her pelvis and spine. Believing Kaiser could have caught the cancer earlier if it hadn’t delayed the MRI, a jury has awarded the patient $28 million in damages.

Kaiser operates as both care provider and insurer, with Kaiser doctors treating patients at Kaiser clinics and hospitals. Some have argued that while this may be good for Kaiser’s business, it’s not necessarily good for the patients to have their HMO actually employing their physicians.

The patient in this case alleged that Kaiser was looking out for its bottom line and not looking out for her when doctors refused her and her mother’s requests for an expensive MRI, but instead directed them to nutritionists and acupuncturists. ...

After three months, Kaiser relented and agreed to the MRI, which found the rapidly growing tumor and led to the surgery that took her right leg.

Oh, guess who else has Kaiser? This guy!

[elleng]

1. This is an awful story.

My good friend has Kaiser (MD suburb of DC,) and is pleased with the service he receives. I've thought of moving my GP to Kaiser there too, as mine is further away from me.

[still_one]

2. There are good and bad physicians at every facility, which is why if the patient

doesn't feel they are get adequate care to get a second opinion, even if they have to pay for it, they can always argue with the insurance company for reimbursement

[arcane1]

4. If they can afford to pay for it in the first place

[still_one]

11. Doesn't. Matter, it is a persons life that is at stake, and like I said they can always deal with

The insurance company later, and if something is found, there is no jury that would not side with the patent if it got that far.

The ACA actually allows for second opinions

[arcane1]

13. They'll let you receive the service without paying in advance, out of network?

[still_one]

15. no, you will have to pay for it if insurance doesn't cover it, but you can fight for reimbursement

Later of course.

The point I am making is if someone does not feel they are getting a proper diagnosis or treatment, they need to do something about it. It is their life at stake.

[arcane1]

16. Ah ok. I see what you're saying.

I was thinking more in terms of someone who doesn't have the money up front, or can't do without it while awaiting reimbursement.

[Doctor_J]

21. and have the time and persistence to win a battle of attrition with the insurance

company.

[elleng]

5. True and, especially after this award,

Kaiser corp is likely to adjust their policies, if/where they are inconsistent, to assure stuff like this doesn't happen.

To some extent it may have been corp, or local corp policy that resulted in OP disaster.

[catrose]

3. Similar for me but not so sad

My new doctor, when I told him of back and leg problems, ordered an MRI to find out what was wrong before deciding on a course of action. I tried to make sure that Cigna would cover it but just got bounced around the company with no answer. So I called the imaging place to cancel because I couldn't confirm coverage, and they said it was their job to deal with Cigna and they would accept whatever payment they could negotiate from Cigna; I wouldn't owe anything. So I went ahead.

And Cigna decided that an MRI for years of pain and loss of function was medically unnecessary, that I should have gone to physical therapy or something first. So they paid nothing, as far as I know. Their reasoning makes no medical sense to me nor does Kaiser's. From an accounting standpoint, I suppose it does. Meanwhile, people are suffering and dying.

[RedCappedBandit]

6. Good. Money is all these people understand.

"The patient in this case alleged that Kaiser was looking out for its bottom line and not looking out for her"

No shit. That's health insurance in a nutshell.

[procon]

7. I've had Kaiser ins since the 80s

first through employers and then Medicare, and several of my family members are also Kaiser members. On the whole, the care is very good. I've never been denied access to specialists, even if they are out of the program. If I want to get a specific test, and MRIs are done in the clinic, my doc generally OKs it, or recommend something more appropriate, but I've never been denied.

Much depends on your relationship with your MD. If you are actively participating in your treatment plan, they do respond in kind. Kaiser has several systems for handling patient complaints, and the only disagreement I had was with an Indian doctor who talked over me to my DH, and even when I asserted myself as an educated woman in full charge of mind and body, he could not overcome his cultural roots to engage me beyond, hand-patting. I switched, and have been with the same Persian doctor for over a decade.

From my own experience, I hope this is just a one-off situation where the doctor totally failed the patient.

[Dont call me Shirley]

18. It was Kaiser's fault not the doctor.

[Oilwellian]

8. How in the hell can you be both...

a health care provider and insurer? What a racket...but hey, that's what America is all about these days!

[Aerows]

9. We will never get health care for all

until we sue the ever living fuck out of insurance companies and make their business unprofitable.

And hospitals.

I'm sorry if that is something that will make those who work at insurance company's and hospital's lives miserable in the short term, the problem isn't with you, the worker. It is with the head of the snake that is the problem, and it has to be cut off for just, compassionate care to happen in this nation.

[shanti]

10. yeah, i have kaiser too

they tried to pull something similar to me. i asked for a colonoscopy as i felt it was a better diagnostic tool instead of the rinky dink test they wanted to do. i had to fight them for it, and wrote a letter to their corporate offices. they then relented. you really do have to go to bat for yourself with them.

another thing that annoys me is that i've been treated since the mid-90's in kaiser's dermatology dept. due to a couple of bcc's. i assumed i was already "their patient" due to my history, but now if i have any skin issues that i feel need to be seen, i have to get a referral from my primary care physician FIRST, which costs me ANOTHER copay! grrr! i really do think that their physicians are told to watch the bottom line and they do!

[still_one]

14. A colonoscopy is the gold standard, you are correct. For such procedures as colonoscopy,

Mammograms, PSAs, if you are in the right demographic, age, or your family history, they are obligated to approve those procedures. However, if you don't fit in those categories, you will need to push your doctor to order it

[daredtowork]

12. Acupuncture - Politics of SF Bay Area

There are many acupuncture schools in the SF Bay Area. The students volunteer their services to the low income community, and they get funding from local governments to implement various social programs.

I don't know what's going on in the LA area (this case was in Woodland Hills - LA Area) - but the medical clinics in the Bay area also have integrated acupuncture programs. I've always been referred to acupuncture for pain management (rather than more expensive and now more heavily regulated pharma treatments for pain). I'm not sure whether acupuncture works or not, but I've always dutifully gone just in case it will help.

This never bothered me until I went to a city commission meeting and studied how local health and human welfare funding was parceled out. People from acupuncture programs came into speak while other programs merely submitted their applications. As a result, several acupuncture programs got funded. What really bothered me, though, was that the acupuncture program for the medical clinic got as much funding as the medical program in Western medicine to serve the elderly. There were several other funded "projects" for the clinic that got less money. I wanted to speak up for what was NOT on the list, western-medicine-wise, but "the public" wasn't allowed to speak.

This made me so angry. I don't want to come out as against Eastern Medicine - especially when there are so many schools in the area, and all those students need jobs. But disabled people suffering from complex conditions really need Western medicine funded, too! And right now it's extremely under-funded! At that clinic, there was for a few months effectively one primary care doctor left who was triple booked all the time! How many severe medical problems fell through the cracks because of that? I had a pretty dicey situation myself during that time! Doctors are sending patients to acupuncture because THAT'S WHAT'S FUNDED!

And it's funded because the acupuncturists are lobbying for it, and the medical clinics aren't even showing up. They are just assuming that local government will know they are consistently underfunded and patients need Western medicine.

Someone needs to do/say something. I'm already trying, but I'm not enough.

[Dont call me Shirley]

17. 17 year old girl...

[AtomicKitten]

19. That is a horrible outcome.

This young girl deserves every penny of that judgment, but I suspect they will appeal and tie her up in court ad infinitum.

My next door neighbor broke his leg. Kaiser delayed treatment for several weeks before authorizing the operative repair he required. He very soon afterwards developed a DVT and dropped dead at the age of 44. Truly a tragic outcome.

[Doctor_J]

20. a uniquely American story

But you can take comfort in the fact that every American has to deal with the same thing, since we are all now required to buy insurance.

[KamaAina]

22. But not Kaiser

[Doctor_J]

23. They are no different from any other. They are required by law to pay as little as

possible out in healthcare. All of them.