Doctors, HMOs Clash at Hearing on ‘Gag Rules’

Doctors and health management industry officials clashed bitterly Thursday at congressional hearings over “gag rules” that some health plans allegedly use to prevent doctors from having full discussions of treatment choices with their patients.

The gag rules “effectively place a wedge between a physician and his or her patients,” Dr. Robert E. McAfee, a former president of the American Medical Assn., told a hearing of the health subcommittee of the House Commerce Committee.

But Karen Ignagni, president of the American Assn. of Health Plans, which represents the HMO industry, denied that such strict rules exist. She insisted instead that many of the complaining doctors are simply upset with the revolution in health care, which is moving millions of people into managed-care networks and away from the traditional system in which patients had virtually unrestricted choices among doctors and hospitals.

Thursday’s hearing was the first major congressional review devoted to managed-care problems.

Opposing sides were carefully balanced at the session, a sign of the ambivalence of the Republican majority in Congress, whose leaders are eager to appear responsive to complaints raised by both patients and doctors but hesitant to impose new laws in an area distinctively free of federal action. Health insurance is a voluntary benefit offered by employers and there is no federal regulation or oversight.

Rep. Greg Ganske (R-Iowa), a surgeon, and Rep. Edward J. Markey (D-Mass.) have 100 co-sponsors for the Patient Right to Know Act, which would prohibit gag rules. A committee vote is expected in July.

But the HMO industry is working hard against the legislation and Congress is likely to be skeptical of passing the first federal rules for health insurance.

McAfee, a surgeon from Portland, Maine, said that the AMA has received 200 complaints from doctors about HMO contracts with restrictive rules.

These include provisions forbidding doctors to discuss treatment options unless the HMO has authorized payment for the specific type of treatment or to tell patients about any financial incentives or penalties that the HMO uses to restrict tests or referrals.

Doctors sometimes are forbidden to refer patients to specialists or facilities not participating in the HMO network of doctors and hospitals, McAfee said. “We are receiving calls up to this moment from people complaining about this problem,” he said.

Dr. Steve Buie of Kansas City, Mo., told the committee that “if we press too hard on our patient’s behalf, we place ourselves in danger of being dropped by the health plan. If we don’t press hard enough, we don’t live up to our oath.”

Dr. Michael Haugh of Tulsa, Okla., complained about battling HMO management for 10 months to get approval for a test to determine if a patient was in danger of having an aneurysm. When he told the patient about the dispute, the HMO chastised him for “inflammatory” action.

Ignagni countered that doctors who complain of gag rules are actually referring to “non-disparagement” provisions of health plans that are legitimately used to prevent doctors from unfairly denigrating the health care networks.

Health maintenance organizations “provide more care and better care” than the system of fee-for-service medicine, Ignagni said.

Defenders of HMO medicine at the session included the medical directors of PacifiCare of California and the Harvard Pilgrim Health Care, who said that their plans have no gag rules or restrictions on physician discussion of treatments.

“We do not believe in limiting the choices which our doctors discuss with their patients,” said Dr. William Osheroff, the medical director at PacifiCare. “We do not believe either that physicians are always unbiased in their treatment recommendations. It might be unusual, for example, for a radiation oncologist to recommend surgery to a prostate patient. He or she would be much more likely to recommend radiation therapy.”

The ambivalence of the public debate over managed care was further reflected in the testimony of witnesses who described their personal experiences with HMOs.

Five persons testified in emotional terms about HMOs. Three gave high marks to their HMO doctors, while the other two denounced HMOs for failing to help their fatally ill spouses.

David Ching of Fremont, Calif., whose experiences were discussed in a Los Angeles Times series on HMOs last year, told of battling doctors for 11 weeks to get his wife, Joyce, a referral to a specialist.

After seeing a specialist, she was found to have colon cancer and died 15 months later. He called for federal laws to prohibit gag rules and to allow patients to go outside their HMO networks for a reasonable fee.

“The next life you save could be your own wife’s, husband’s or child’s,” he told the committee.

An HMO believer, Lauren Hirsch of Wantagh, N.Y.--with her 3 1/2-year-old daughter Chelsea in her lap--spoke of two lifesaving liver transplants for Chelsea, with the enthusiastic cooperation and support of the Aetna Health Plans.

“She has been given back her childhood,” she said of Chelsea. “And I think the only bills we’ve had in this whole ordeal . . . are some plane tickets, some hotel stays that we picked up. Out of hundreds and hundreds of thousands of dollars, we had to spend maybe $3,000,” she said.

Another enthusiast, Diane Martello of North Tarrytown, N.Y., a mother of three who was too busy to go to the doctor, told of persistent HMO physicians who forced her to get tests, discovered a serious heart enlargement and insisted on surgery to avert an aneurysm that could have killed her.

An HMO critic, Alan Charles deMeurers of Keizer, Ore., said that his late wife, Christine, had to fight breast cancer and the HMO at the same time as she tried to get accurate information and a referral for a transplant procedure.

But Alfred Couture of Worchester, Mass., declared that his HMO doctors were devoted and efficient, providing first-rate care for himself, his wife and nine children, including emergency surgeries.

“Stay well,” he told the committee, “but if you need medical care, I hope it is the same type of care we received at our HMO.”