Invariably, HMOs promise patients that the physicians on their "provider lists" are carefully screened and monitored.
Fact: Last fall, the New York Public Health Service randomly studied the network rolls of 31 HMOs, and found 51 doctors whose licenses to practice had been suspended or revoked for reasons related to patient mistreatment. That's 51 unlicensed doctors.
Is your HMO doctor qualified? Licensed? In good standing at the hospital you may use one day? The answer is probably yes, but you can't count on it.
Some HMOs check the bona fides of their physicians frequently. Some don't.
Our two-part investigation, reported and researched by producer Jill Rosenbaum, begins with the story of Sherra and Tony Lombardo of Plano, Texas. The story exposes a huge loophole in HMO patient protections for us all.
In February of 1997, Sherra was 26 weeks pregnant with twin boys, and under the care of Dr. Kevin Hatchet, a Plano obstetrician-gynecologist. Sherra's pregnancy had certain complications that made her pregnancy high risk, in addition to the fact that she was carrying twins. This made it essential that she be able to reach Dr. Hatchet.
About halfway through the pregnancy, Sherra pre-certified her hospital delivery with her insurer, Blue Cross of Texas. The HMO, in writing, green lighted her to have the twins delivered at the Columbia Plano Medical Center, specifically by Dr. Hatchet.
One night just two weeks later, she began having sharp pains. Assuming it was too early for labor, she called and left a message with Dr. Hatchet's answering service. No call back. The pains continued. She called again, with no luck. After several calls were not returned, and after more than two hours, Dr. Hatchet's nurse called back and advised Sherra to take Advil and lie down. Dr. Hatchet couldn't be found.
After three hours of pain, and angry about the advice to take Advil, Tony and Sherra went to the hospital. The on-call specialist in obstetrics and gynecology, Dr. Christopher Riegle, immediately realized Sherra was well into labor. He struggled to stop the labor and was successful for almost three days. When the twins were finally born, they were severely premature.
Two long weeks later, the ombardo twins died, because their brains were too immature to survive. There's no way to say for sure if an immediate halt to Sherra's labor during those lost three hours would have saved the twins, but most experts agree it was their only hope.
Where was Dr. Hatchet? It turns out Dr. Hatchet had a drug problem. A string of patient complaints had cost him his hospital privileges at three north Texas hospitals. At Columbia Plano alone, he had lost privileges five times.
The Texas State Board of Medical Examiners was well into an investigation that eventually found Hatchet had been abusing cocaine, Xanax, alcohol and a list of self-prescribed medications. His license to practice medicine in Texas was taken away.
Sadly, Dr. Hatchet was a well-respected physician in the middle of a downward spiral. His troubles were well known to his colleagues, to the state and to several area hospitals.
But not to the HMO.
Why didn't Blue Cross know? How could it give the green light to a physician who for months couldn't even have entered the hospital to see patients?
Our investigation, based on public records, court files and background conversations with knowledgeable sources, reveals that Blue Cross did little if any credential checking on its own. Instead, the health plan contracted out the job to what is called a "CVO," a credential verification organization, in this case a company called System Health.
Court testimony indicates System Health was meeting Texas' minimum requirement of checking the licenses of the Blue Cross doctors every two years, but had no system for periodic checking in the interim. Other credentials, including hospital privileges, simply weren't checked.
We found this is not uncommon. About half of the HMOs in America sub out their credential checking and monitoring to CVOs. These are legitimate businesses offering efficiency to scores of HMOs that operate in the same metro area, but they are only as good as the HMO demands. Some HMOs work hard at overseeing this work, and some don't.
The HMO industry lobby, the American Association of Health Plans, insists that most reputable HMOs today do ongoing random checks of key physician credentials including medical licenses, DEA licenses, hospital privileges and malpractice pay-out records. However, the AAHP acknowledges there are "gaps" in reporting troubled doctors, especially in cases in which the HMO or its contract CVO fails to screen their physicians frequently.
The irony is, it is easy for HMOs to get all of this information. Basically, it's available at the touch of a button.
The federal government runs the National Practitioner Data Bank, a database of all adverse actions taken against the nation's doctors. All hospital suspensions over 30 days, license suspensions and revocations, DEA license removals and malpractice pay-outs are in the data bank.
Any hospital or health plan can access the data using the Internet. It takes just a few oments.
By law, the public is barred from accessing this database. However, there are a few places people can go for information about their doctors.
One is the book published by Public Citizen, a health-care watchdog group headed by Dr. Sidney Wolfe. It's called Questionable Doctors, and it lists thousands of doctors. A new edition is about to be released. The book is available through the Public Citizen site. You'll find it in their list of health-related publications.
In addition, DoctorDirectory.com offers access to information on doctors including board certification and medical school training. The site also has Best DocFinder, an application that, for a $25 fee, provides referrals to doctors who rated highly in a survey of physicians in any specialty.
An online service called MediNet charges $14.75 to do a search on a doctor.
Most state medical boards will give some information, if queried by fax or phone.
Also, check to see if your state has online information about doctors. Florida and Massachusetts do the most comprehensive profiling of physicians. Florida's site has information under the heading "Practitioner/Physician Profiling" in the pull-down window at the top of the page.