Doctors sue Woodland Hills-based Health Net over denying patient surgeries

[Steve Williams]

IMO this is long overdue. Time to stop looking at managed care as "lives" rather than as "patients"

By Susan Abram, Staff Writer


Physicians from across the state filed a lawsuit Thursday against Woodland Hills-based health insurer Health Net, claiming the company denied life-changing surgeries to patients, causing needless pain and suffering.

The Los Angeles County Medical Association filed the lawsuit on behalf of physicians and two patients. It also sought an injunction prohibiting Health Net from using the term "medical necessity" as a reason why procedures can be denied.

In one case, Health Net had their in-house gynecologist review the medical file of a woman in need of spinal surgery. Based on the gynecologist's assessment, the woman's surgery was denied because the procedure was not deemed a medical necessity.

The lawsuit calls the act an unfair and unlawful business practice.

These practices "present a continuing threat to the public's health, safety, and welfare," according to a statement by the Los Angeles County Medical Association.

"Once again, we see health insurance company putting profits ahead of patient health and lives," said Rocky Delgadillo, the chief executive officer of the L.A. County Medical Association and former Los Angeles city attorney.

"By deciding which medical treatments are necessary and which ones it will cover, Health Net is dictating medical care from the boardroom. Patient care should be decided by doctors, not business suits."

Health Net said in a statement Thursday that it aims to ensure members receive appropriate access to necessary medical care.
"Medical care is complex, and sometimes there are differing medical opinions as to what constitutes medically necessary care. In these instances, Health Net carefully follows the guidelines established by the state of California's two regulators, the Department of Managed Health Care and the Department of Insurance," the company said.

"These regulatory procedures provide a ready path for members to seek review of Health Net decisions by medical professionals who are not affiliated with Health Net. If the independent, expert reviewer determines that the desired treatment is medically necessary, then Health Net covers it."

 

[MylesBAstor]

I predict they'll settle out of court.

 

[Mosin]

When a managed care company manages or owns a hospital, the situation is even worse. My wife has worked in several managed care environments. In all instances, aides and secretaries were dressed like nurses, and various other personnel were made to look more qualified than they actually were because short-staffing was the rule, not the exception. These outfits care only about the bottom line, and the patient is merely a way to get there. For them, the staff is just another necessary part of overhead. Supplies are the cheapest that money can buy with quality not being a factor. Demands on those who work there disregard the time required to accomplish the work competently, and everyone is easily dispensable to the bureaucrats who run the places. Only a warm body is required by HR, not qualifications. The patient, on the other hand, doesn't even have to stay warm, but he does need insurance, private resources or good credit. Otherwise, he is quickly dumped.

Every time my wife went to work she felt as if her license was on the line. Things were so bad that she finally took a tremendous pay cut and went with a non-profit hospice. She never looked back.

 

[MylesBAstor]

When a managed care company manages or owns a hospital, the situation is even worse. My wife has worked in several managed care environments. In all instances, aides and secretaries were dressed like nurses, and various other personnel were made to look more qualified than they actually were because short-staffing was the rule, not the exception. These outfits care only about the bottom line, and the patient is merely a way to get there. For them, the staff is just another necessary part of overhead. Supplies are the cheapest that money can buy with quality not being a factor. Demands on those who work there disregard the time required to accomplish the work competently, and everyone is easily dispensable to the bureaucrats who run the places. Only a warm body is required by HR, not qualifications. The patient, on the other hand, doesn't even have to stay warm, but he does need insurance, private resources or good credit. Otherwise, he is quickly dumped.

Every time my wife went to work she felt as if her license was on the line. Things were so bad that she finally took a tremendous pay cut and went with a non-profit hospice. She never looked back.

What irks me about managed care is that it really doesn't work.

That aside, they only answer to their stockholders and making a profit is more important than anything. I don't know about you, but I'd rather see my doc getting the money than these stupid stockholders.

 

[audioguy]

I was involved in the healthcare industry for 10 years. It was and is "managed cost" NOT "managed care".

And guess what, what happened with HealthNet is EXACTLY what eventually will happen with our new Health Care approach - just watch. As you age and when you need some kind of major surgery, the ability for you to obtain the surgery will be dependent on if someone decides what your long term "value" after the surgery.

 

[DaveyF]

I predict they'll settle out of court.

Myles, you are so right. What a pity that rapacious companies like this cannot be put out of business and gotten rid of once and for all, just IMHO.

 

[KeithR]

We need cost controls at some point. While I'm not saying anything about this particular incident--there are a zillion MRIs a year that are worthless and docs are just playing CYA.

audioguy- so what about paying 100k in biotech drugs to keep someone alive for 60 days in late stage cancer? we as a society are going to have to figure out what we want to pay for. in your example, i would hope your doctor could determine the long term "value" of the surgery before it ever went to an insurer.

 

[Phelonious Ponk]

Gotcher "death panels" right here.

Tim

 

[jazdoc]

This part of the health care debate is silly on both sides. We ration all sorts of things. I drive a car with nearly 100,000 miles on it. Could I afford an S class Mercedes? Yup, but I have kids to send to college and I'd like to retire some day. So I ration my automobile spending. I even ration my vinyl spending (and no catcalls from Mike Lavigne on that one!).

Of course we ration healthcare because the demand exceeds the supply. That is not the issue. What is the issue is do we decide as individuals with our families how to ration health care expenditures or do we want the amount of available care rationed by the government? Do people with greater financial resources have greater flexibility and ability to spend money on healthcare...of course. Is it fair...good question. Does accepting/demanding healthcare resources from your fellow citizens obligate you to change unhealthy behaviors in order to continuing receiving such benevolence?...also a good question.

 

[mep]

After spending 3 hours in the local ER last Saturday after I tore my tendon, it was obvious that people use the ER as they would a family doctor if they had one and could afford to pay him/her. The ER looked like WalMart had just closed their doors and the customers needed someplace to go. Same freak show, different location.