HMO Denies Heart Patient Access to Cardiologist and Hospitalization For Drug Treatment

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Stephen Keller- Pacifica, CA

As told by Stephen Keller:

I have a condition called "atrial fibrillation" which is an irregular rhythm of the heart. I take medication to control this. I have had this condition for 10 years.

Three things happened to me while I was insured under an HMO that I consider to be medically dangerous decisions. First, my wife called the office of my MD to inform them I was having an attack of atrial fibrillation. The office told her that the doctor was booked up and couldn’t see me. We went to my cardiologist instead. (We pay for an individual health plan because my cardiologist, who I have been going to for 8 years, wasn’t on the HMO plan.) If we were medically uneducated or didn’t have enough money to pay to see the cardiologist, I would not have had any medical attention at all when my heart was beating irregularly.

Second, my cardiologist wanted me to change medication to a drug called Cordarone. He told me that I would be hospitalized for about five days while I took a very high dose of the drug to build it up in my system. I would then take a lower dose daily. The HMO refused to pay for the hospitalization. As a result, I had to take a lower (but still quite high) dose at home over a longer period of time.

During the first two weeks, I was unable to go to work as my wife had to watch me for side effects of the drug. After the dose was lowered, I could go to work, but could not drive; a co- worker had to pick me up to go to work. All in all, it was 6 weeks before I was lowered to the maintenance dose and could resume normal activities.

Third, during the period when I started on Cordarone, I had several attacks of fibrillation. On one occasion it was late at night, so my wife took me to the emergency room. They put me on a heart monitor a couple of hours, then sent me home while my heart was still beating irregularly. In the past, on another health plan, the hospital had admitted me for observation when I went to the emergency room. I believe that they sent me home because they knew the HMO plan would dock them under the capitation agreement. This happened more than once when I was under the HMO plan.

I have been lucky so far, but the law needs to be changed to make HMOs more accountable for the cost cutting decisions that they make. I get my health care through my employer so I fall under what is called an ERISA plan. ERISA, the Employment Retirement Income Security Act, shields my HMO from damages if they make a cost cutting move that maims or kills me. If I could find a lawyer to represent me, I would be able to collect only the cost of the care that was denied me. However, lawyer fees are not even guaranteed under ERISA, so finding representation would be difficult too.

ERISA works like a bank robber who gets caught robbing a bank and the only penalty they have to face is returning the money they’ve stolen. No jail time…nothing. If that were the law, many people would give up their day job and take advantage of such a lax system. This is what is happening within the HMO industry, under ERISA. HMOs know there is no legal recourse if they deny or delay expensive tests that may lead to expensive treatments. They have no incentives to go the extra mile or even just give standard care.

The ERISA loophole must be closed and HMOs must be held accountable for the decisions they make.

Consumer Watchdog
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