MEDICAL CARE: THE SOUL OF AN HMO

(12 of 15)

One week after the merger pact was signed, after a bone scan found that Christy had indeed responded to the initial chemotherapy, the deMeurerses signed an agreement of their own with UCLA, promising to pay up front the full cost of the treatment: $92,000, an amount equal to 0.08% of the $11.7 million that Health Net had accumulated in its transplant pool by the end of 1993.

Suddenly Dr. Glaspy, who by now had learned that Christy was a Health Net subscriber, found himself walking the fault line between the old medicine and the new. The dimensions of his conflict became clear on Thursday, Sept. 9.

That morning, in his old-medicine role as advocate, he signed a legal declaration "in support" of Christy's fight for an injunction. At 3 o'clock that afternoon, wearing his new-medicine hat, he and two UCLA colleagues met with other oncologists and Health Net officials at the Hyatt Hotel near Los Angeles International Airport for another meeting of the company's bone-marrow committee.

A tape recording of the meeting shows the extent to which business and medicine have become entangled in California, and raises the question, When does a patient's insurer determine the range of options a patient is allowed to consider? The question was asked directly by one of Dr. Glaspy's colleagues, Dr. Peter Rosen. "I guess I'm not quite understanding something," he said, as the meeting gained heat. "If you know someone's a Health Net patient, do you talk to them differently than if they're somebody else?"

The talk at the meeting quickly turned to the matter of patient deception. "The biggest problem," Glaspy told the Health Net officials present, "is when they come to a center and they don't come with a pre-call from you, so we don't know who they are, and we don't know they're from Health Net." Alluding to Christine deMeurers, he said, "We had one of those where that was the problem."

Ossorio argued that the best way to avoid the problem was to make sure all Health Net oncologists received the "grid" that set out specifically what the network would and would not cover. Most of the network's doctors were "pretty comfortable" with it, he said.

But the fact was, some oncologists at the meeting had done transplants for advanced breast cancer. "We have a protocol to treat breast cancer," UCLA's Rosen said. The panel, he cautioned, had agreed only that such transplants should not be covered as a general rule. "That didn't mean we necessarily have all agreed that this is a worthless thing to be doing," he said. "I think that could be a real problem."

At one point, Health Net's Dr. Ho seemed to lose patience with the doctors' ambivalence. "Each of these issues--I just want to be clear about this. This is not a Utopian society that everybody can be everything to all people and paid for by somebody else. We have fiduciary responsibilities to our employers to the tune of about $1.5 billion worth of premiums paid to us every year to manage their health-care premium dollars responsibly . because in general, insurance and payers and physicians have been ineffective in holding that fiduciary responsibility."