By David S. Hilzenrath
Washington Post Staff Writer
Monday, August 7, 1995; Page A01

Costella Prince Thompson was feeling wretched when she went to a Group Health Association Inc. urgent care center on March 12, 1992. Since undergoing general anesthesia for arm surgery a little more than a week earlier, she had experienced a sore throat and a cough along with diarrhea, chills, nausea and vomiting.

At the health maintenance organization, the 53-year-old D.C. schoolteacher was examined by a physician assistant, who prescribed some medicine and sent her home with instructions to stay in bed for four days.

A day later, Costella Thompson was dead. An autopsy revealed pneumonia and other serious problems that the physician assistant had missed, apparent complications of her surgery.

A District jury faulted the care Thompson received at GHA, but decided four months ago that the HMO was not to blame for her death.

As cost-conscious insurers transform the health care system, some experts are applauding them for bringing greater efficiency to medicine. But many patients and medical professionals, citing cases such as Thompson's, argue that the system is cutting corners as well as costs.

Silver Spring physician Bernard A. Heckman sees Thompson's case as an example of the potential trade-offs society faces in its push for more economical health care. "The emphasis on cost containment is going to bring about a deterioration in overall quality of care," he said.

There is little if any authoritative data to show whether the quality of medical care is getting better or worse overall -- in fact, there is little consensus as to how to measure quality, experts say. But the first signs are appearing that Americans will have to accept compromises when they seek medical services:

A recent survey by the Robert Wood Johnson Foundation found that sick patients enrolled in "managed care" -- the rapidly growing form of health insurance that tries to contain spending on medical services -- had many more complaints about their care than sick patients with traditional "fee-for-service" insurance coverage.

Managed care patients were at least 40 percent more likely than fee-for-service patients to report that they had problems getting needed treatment, were unable to see a specialist when needed, were unable to get needed diagnostic tests and had to wait a long time for routine appointments.

At one Fortune 500 company, 26 percent of the people who sought treatment for mental health or substance abuse problems through the employee benefits program received no care within three months of requesting it, largely because of delays in authorization or other administrative problems, according to James Wrich, a Chicago consultant who was hired by the company to evaluate the program. The benefits plan required therapists and patients to get treatment approved in advance by a managed care contractor, which reduced expenses by about 30 percent.

Generally, "you had to have a serious crisis . . . in order to get help," said Wrich.

At California Pacific Medical Center in San Francisco, organ transplant specialists have turned down patients who might have been given transplants in the past even though they had poor prospects for recovery, said Barry Levin, vice chairman of the hospital's department of transplantation. Without transplants, these patients have no chance of survival, he said.

Because health insurance plans now cap payments for the surgery and follow-up care, "the sicker the patient is, the less chance you're going to have . . . of making a profit or breaking even on the case," Levin said. "You unconsciously or even consciously begin to look at patients differently."

One HMO doctor refused to see a woman who repeatedly sought an appointment for chest pains, said Margaret E. O'Kane, president of the National Committee for Quality Assurance, an accrediting agency that monitors quality control in HMOs. Traditional health insurers pay doctors a fee for each office visit, which critics say encourages unnecessary care. But the HMO paid this doctor a fixed monthly fee to provide all of the patient's primary care, whether the doctor saw the patient or not -- an increasingly common approach.

In Easton, Md., physician Donald T. Lewers, a trustee of the American Medical Association, said one health insurance plan refused to pay for Pravachol, the drug he had been prescribing to control a retired factory worker's high cholesterol. The insurer insisted that the woman instead use Mevacor, made by a different manufacturer, even though Mevacor had proved less effective for this patient when she had tried it several years ago, Lewers said. Unable to pay for Pravachol out of her own pocket, the patient switched to Mevacor in February, which placed her at increased risk of heart attack or stroke, Lewers said.

A spokesman for Merck & Co., which makes Mevacor and administers this patient's prescription drug benefit through a subsidiary, said the plan would cover Pravachol if the doctor wrote a note that it was medically necessary. Lewers said the company representative who asked him to switch the prescription did not mention that option.

"We'll have to make some sacrifices and pay a price for less costly medical care," said Stanford University health economist Alain C. Enthoven, who sees the health care revolution doing more good than harm. "That means everybody can't have everything all the time. . . . In some cases that may reduce the quality of care."

At a June meeting in Jackson Hole, Wyo., a group of large employers who have helped lead the drive for less expensive health care resolved that they would develop better ways of tracking changes in their employees' health. The current focus on costs "could be ruinous to the health care system" unless it is balanced by greater emphasis on medical results, said Dwight N. McNeill, an employee health benefits manager for GTE Corp. and a coordinator of the group's efforts.

Even some of the most vocal critics of the cost-cutting measures agree that the health care system must be made more efficient. Rising medical bills have become a heavy burden for society, pricing private health insurance beyond the reach of millions of Americans, threatening to overwhelm the government health insurance programs for the poor and the elderly, and diverting money from other priorities.

Neil Schlackman, medical director of U.S. Healthcare Inc., a large HMO company based in Pennsylvania, said the nation has been consuming so much unnecessary, inappropriate and potentially harmful medical care that it is possible to improve quality while cutting costs.

"I think we're still {cutting} fat," Schlackman said, echoing the view of many in his industry. "There's a huge opportunity still available before we get into muscle and bone."

The Denial of Service

The driving force behind health care cost-cutting has been big employers' search for less expensive ways to provide health benefits for their workers -- and the rise of managed care health insurance plans such as HMOs to do the job.

Where traditional insurers simply paid their customers' medical bills, managed care plans often require doctors to get approval before ordering certain tests or procedures. They steer patients to doctors and hospitals that accept their reimbursement rates and meet their standards. Patients who seek care elsewhere must pay a larger percentage of the charges or the entire cost themselves.

"In the overwhelming majority of HMOs as far as we can tell, the denial of needed services is not a major problem," said Bruce C. Vladeck, administrator of the Health Care Financing Administration, which oversees federal insurance programs for the poor and elderly. But, speaking generally, he added, "We have a long history . . . of really fundamentally abusive or dishonest plans where the denial of service has been part of the get-rich-quick strategy."

Managed care plans covered 65 percent of workers insured through mid-size and larger employers last year, up from 29 percent in 1988, according to the consulting firm KPMG. Doctors who lose favor with those health plans on grounds of cost or quality may be cut off from large blocs of patients and major sources of income.

One mental health professional said she has become hesitant to accept severely ill patients or see patients more than once a week as a result of warnings that Mid Atlantic Medical Services Inc. (MAMSI), a Rockville-based managed care company, has issued about "utilization" -- jargon for services delivered or resources consumed. "It makes me very cautious to take patients who require any kind of intensive treatment," she said, speaking on the condition that she not be identified.

She was referring to messages such as an Aug. 9, 1994, letter to Mid Atlantic mental health providers in which Assistant Medical Director Mark D. Groban said: "Those providers who maintain significantly higher utilization than their peers will have additional utilization management review of their MAMSI case load to ensure that only high quality and medically necessary care is being delivered. . . .

"We have a large waiting list in each of our mental health specialties and see no reason to ask providers to work with us in a model that is uncomfortable for them."

D.C. malpractice attorney Jack H. Olender said he believes a cost-sensitive atmosphere contributed to Group Health Association's failure to diagnose the colon cancer afflicting his client, Lilia M. Reyes.

Beginning in October 1991, Reyes, a program manager for the U.S. Conference of Mayors and a mother of two, complained to GHA of abdominal pains, bowel irregularities and other problems. By early 1992, when blood was detected in her stool, she told her GHA doctor that she feared she had colon cancer, according to court records of a malpractice suit.

At a trial last year, expert witnesses for Reyes testified that at the outset of Reyes's treatment she should have been given a sigmoidoscopy, which almost certainly would have revealed her problem. A cancer specialist called to testify by the HMO said that test would have been "acceptable" but not "necessary."

Physician Karen Bledsoe, an employee of the HMO at the time, diagnosed Reyes's problem as irritable bowel syndrome. Bledsoe testified that, before she could refer a patient to a specialist for a sigmoidoscopy, she would have to submit a form for review by GHA's chairman of internal medicine. She said she was denied such requests in some other cases.

Reyes's cancer was diagnosed in August 1992 when she underwent emergency surgery while on vacation in Florida. A tumor had blocked her colon. One of Reyes's experts testified last November that he "would be surprised if she is still alive in a year."

Reyes, 44, said in an interview that she gave up her traditional health insurance and enrolled in GHA in 1991 because the premiums were lower. "Sometimes you try to cut corners thinking you're going to be saving some money, and ultimately you end up paying just an incredible price for it," she said.

In December, a D.C. Superior Court jury ordered GHA to pay damages of $2 million. The case is on appeal. A spokesman for Humana Inc., which bought GHA and renamed it Humana Group Health Plan Inc. last year, declined to comment on the Reyes and Thompson cases, as did lawyers who represented GHA.

The Quality Equation

HMOs have the potential to greatly improve the practice of medicine because they can collect data on what works and what doesn't for large numbers of patients and help standardize patient care, analysts and industry executives say. U.S. Healthcare, for example, sends doctors and patients periodic reminders for vaccinations, mammograms and other screenings. Last year, the Pennsylvania-based company began sending letters to all the suspected diabetics in its HMOs and their physicians, saying the patients should get annual eye exams because diabetes would put them at higher risk of developing a retinal problem. The percentage of suspected diabetics receiving eye exams rose to 41.6 percent in 1994 from 35.9 percent in 1993, the company said.

On balance, Stanford's Enthoven said, care is improving as managed care systems bring independent quality control to doctors' historically autonomous medical practices.

However, the effects are difficult to quantify. "We don't have very much information on how the system is performing," said O'Kane, the National Committee for Quality Assurance president.

The financial payoff for the public is easier to see. The cost of employer-sponsored health benefits, which was rising an average of 17.1 percent in 1990, declined an average of 1.1 percent last year, according to a survey by the consulting firm A. Foster Higgins & Co. Some health plans are offering to cut large employers' rates by as much as 10 percent next year, benefits consultants said.

Various financial interests cloud the debate over what is happening to quality and access. Many of the harshest critics of the health care revolution are doctors and nurses whose incomes are threatened. But many of the revolution's strongest exponents -- the leaders of the managed care industry -- are profiting greatly from the cost-cutting. They pay themselves, their employees and their shareholders with money they squeeze out of the system.

A Pressure to Discharge

Hospitals are caught in the squeeze, and one result is pressure to send patients home quicker.

For example, from 1984 to 1994, the average length of hospital stays declined from seven days to three days for simple mastectomies, from 11.8 days to eight days for heart attacks, and from 2.6 days to 1.6 days for normal deliveries, according to HCIA Inc., a health care information company.

Many newborn babies and their mothers are being sent home within a day of delivery. A study released in May by Augusto Sola, director of neonatal clinical services at the University of California, San Francisco, linked the declining length of hospital stays to an increasing number of cases in which newborns have developed a rare form of brain damage.

Sola said it could cost $40 million to keep newborns hospitalized long enough to prevent just one case of brain damage, but he added that there might be a more economical alternative involving heightened follow-up care after infants leave the hospital.

In the pursuit of efficiency, hospitals, HMOs and doctors' offices have been assigning certain responsibilities to less highly skilled, less highly compensated personnel. One goal is to free the more highly trained professionals to focus on the more complicated work.

Critics say the strategy may increase the likelihood of error.

At an Indiana hospital, a nursing assistant recorded an infant's temperature during a routine check of vital signs, but she did not realize that the reading was dangerously low and did not alert other members of the staff, according to her supervisor.

At Group Health Association, the physician assistant who examined Costella Thompson the day before she died "could not be expected to know any better," but the HMO erred by allowing him to treat Thompson's "life-threatening illness," Heckman, a gastroenterologist, said in a deposition for a lawsuit filed by Thompson's widower, Duane E. Thompson.

According to an autopsy report, Thompson was suffering from a punctured esophagus, an internal abscess that extended from the surrounding tissue to her lung, and pneumonia. The puncture apparently occurred when a tube was inserted in Thompson's throat during her March 4 operation.

Physician assistants, certified professionals whose formal training is less extensive than that of doctors, are typically paid about half as much as family physicians and play an increasingly important role in health care. "Although once considered with trepidation, physician extenders, such as physician assistants, nurse practitioners and midwives, are now seen as a means to boost practice productivity," an American Medical Association publication reported in February.

A D.C. Superior Court jury in April found that two doctors and a nurse committed malpractice in Thompson's surgical and postoperative care. The jury concluded that Group Health Association "departed from the standard of care" in Thompson's case. But it ruled that GHA's lapse was not a "proximate cause" of her death and assessed no damages against the HMO.

By the time Thompson saw the physician assistant, her illness "was too far advanced and too serious to have been reversed," Kenneth T. Larsen Jr., former chairman of the Department of Emergency Medicine at Greater Southeast Community Hospital and an expert witness for the HMO, said in a deposition.