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What Your HMO May Know About Your Doctor, But Can't Tell You

In Part 2 of a series for CBS Evening News Eye on America, Correspondent Wyatt Andrews reports on why patients aren't told what an HMO may have in its records about the quality of their doctors' care. And, he talks to one parent who believes earlier access to such information might have saved her son's life.

Nine-year-old boys aren't supposed to die of heart failure, but Alex Giles did. He had fainted several times while playing sports. Heart trouble might seem to have been a possibility, but his doctor told Alex's mother Bridget that the problem was dehydration or an ear infection.

Bridget was sure that nothing was seriously wrong with Alex. "It couldn't have been. I mean, I had taken him to the doctor five times," she says.

After Alex died, Bridget Giles began to wonder why Alex's HMO doctor, Charles Holmsten, had never considered a heart problem. That's when she looked in his file. She had access to it because she happened to be a supervisor at the HMO, Houston-based NYLCare.

In the file, she said, she found that Dr. Holmsten had badly failed the HMO's own standard for treating children. She testified about what she saw in the file in her lawsuit against NYLCare. The minimum passing score for their office site review was 60. He got an 8.

"They screened him; they knew he was incompetent," says Bridget.

Patients aren't told what an HMO may know about a doctor. That information is shielded by law. When a doctor has a record of incompetence or malpractice, the HMO can find out, the hospital can find out, but the patient cannot.

"We don't know how many times every day a physician who has had a bad report like Dr. Holmsten had on internal testing is permitted to see the next patient," says Price Ainsworth, a lawyer who represented Bridget in her suit against NYLCare.

Ainsworth says a cloak of secrecy surrounds problem doctors. HMOs know about these doctors, he says, but they don't always tell patients and they don't always act upon the information.

"That's the significance in this case, that the HMO had the information and didn't do anything about it," he says.

The industry response may surprise you. Industry spokesperson Susan Pisano says health plans would expel more incompetent doctors, but they are hampered by laws that protect physicians.

In fact, she says, "it's hard for managed care plans to remove physicians from their network."

Bridget Giles says her son should have been protected from Dr. Holmsten. "We're not talking about someone who got a 59. We're talking about someone who got an 8," she says of his review score.

Dr. Holmsten's file is still secret, but in a letter to CBS News, his lawyer argued that the doctor's score reflected only "NYLCare's paperwork requirements and not quality of care." He also wrote that Dr. Holmsten "enjoys a good reputation for quality patient care."

But Bridget Giles believes the cloak of secrecy surrounding that file may have led to the death f her son.

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