MEDICAL CARE: THE SOUL OF AN HMO

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When Dr. Jones examined Christy deMeurers, he believed a transplant could help her. "The available proof for its efficacy in breast cancer was at least equivalent to many other procedures that we do every day," he says. As early as 1990, even Health Net had found evidence that bone-marrow transplants might become a standard weapon against breast cancer. That year the company's then chief medical officer, Dr. Leonard Knapp, ordered a study by Technology Assessment Group of San Francisco to evaluate the treatment. The report, however, didn't reach the conclusion he had hoped for. It found that 3 out of 4 insurers paid for such treatments and, moreover, that by 1991 transplants would probably become "prevailing practice among practitioners, providers and payers."

Dr. Knapp told TAG's project director, Janna Lee Smithey, he was "very disappointed" in the report, she testified in the 1993 civil trial. When she asked him why, he replied, "Because you didn't tell me it was experimental." He said it in a joking way, but in fact the report had perturbed Dr. Knapp, who stated in his own deposition that the report's data did not support its conclusions; he recalled raising "a little hell about it." The report apparently was never circulated very widely. In depositions last year, both Dr. Ossorio and Dr. Sam Ho, by then Health Net's medical director, stated that they had never seen it and knew nothing of its findings.

On June 8, 1993, the day the deMeurerses met with Dr. Jones in Denver, Health Net, with Dr. Ossorio's support, formally decided the company would not cover a transplant for Christy on grounds that it was excluded under the investigational clause of her contract.

A week later, Christy, accompanied by her mother, returned to Dr. Gupta, whom they still viewed as a beacon of warmth. "There's lots of hope, lots of things to do," Nesmith recalls his saying. Christy, dissatisfied with her reception at Scripps and reluctant to undergo months of treatment away from home, wanted a referral for a second local evaluation, this time at UCLA. Dr. Gupta agreed to make such a recommendation in writing, says Nesmith. He told Christy and her mother to go somewhere for lunch and then come back; the letter would be ready.

They returned to find a very different man. Suddenly, Nesmith recalls, "we were like a piece of rock. There was a total 180¡ turn." Dr. Gupta, his demeanor gone cold, now said he was not qualified to make recommendations for a transplant.

Christy insisted that he explain his change of heart. "And he became very incensed and got up and walked out of the office without further commenting or anything," Alan deMeurers said in a deposition last May. Says Nesmith: "It was just such a devastating thing to know that he'd said yes, this was the way to go, then two hours later have him change his mind."

Dr. Gupta confirms he saw Christy that day but says he does not recall this aspect of their encounter. He did not in fact have the authority to make such referrals, he says; these can only be made by a patient's primary-care physician. Asked why, then, he felt empowered to make the first referral to Dr. McMillan at Scripps, he says, "I knew those people one-to-one."