Patient Who Had Stroke Sues Over HMO Care

In a case that could test the extent of a managed-care group’s liability for patient welfare, an Oxnard woman has sued the director of a large physicians association alleging that he denied her request for a brain scan just two weeks before she suffered a paralyzing stroke.

Joyce Wooton, 66, said in a lawsuit filed Wednesday that she would not have had a stroke if the medical director had followed her doctor’s request for a CAT scan when she sought treatment last summer for headaches and numbness in her hand and leg.

According to the lawsuit filed in Ventura County Superior Court, that request was denied by Dr. David Mescher, head of the Oxnard-based Sea View Medical Group. That decision was made despite a doctor’s recommendation for the scan and without Mescher ever having examined Wooton, the lawsuit says.

Sea View is a medical group that contracts with insurance companies to manage care for about 60,000 patients.

“I’d like to fix what’s wrong here,” said Wooton, a retired civil servant who said she has lost use of her right arm and is no longer able to perform a range of basic functions such as driving a car or opening a can of food.

“I’d like it to be where if someone else comes along and needs a CAT scan, they get it,” she said. “I want to make sure no family has to go through what we’ve been through.”

Neither Mescher nor any other representative of the Sea View group could be reached for comment Thursday.

The lawsuit was filed on Wooton’s behalf by Oxnard attorney Mark Hiepler, known for his legal battles against HMOs.

He said the case is novel in that it seeks, perhaps for the first time, to hold the head of a medical group directly responsible for a patient’s care.

“We believe the nameless, faceless deniers of care . . . should be held to the same responsibility as the people who tried to treat her,” said Hiepler, who won a landmark $89-million jury verdict in 1993 against Health Net for denying a bone marrow transplant to his sister, a breast cancer patient who died that same year.

“It points up the national dilemma over who’s actually taking care of patients,” Hiepler said. “She [Wooton] got lost in the bureaucratic mess of managed care. Her goal, as is ours, is to change the system.”

Initially, Wooton’s goal was simply to find out what was wrong when she started feeling sick in July of last year.

According to the lawsuit, Wooton went to her doctor, Wallace A. Tamayose, with signs of carotid artery disease. Tamayose, who is not a defendant in the lawsuit, feared medical complications, including a stroke, and ordered the CAT scan, the lawsuit says.

About a week later, Wooton was told that Mescher had determined that the CAT scan was not needed, despite the fact that he had not examined the woman, the suit says. Over the next two weeks, she said Thursday, she called her medical provider to see what was being done about her condition and each time was told that officials were trying to work things out.

On Aug. 17, a day after her 66th birthday, she said, her arm started to feel heavy and she started slurring her words. She called her son, Tony Wooton.

“I went over immediately,” said the younger Wooton, sitting with his mother Thursday in Hiepler’s Oxnard office. “I know her voice and I know she was scared.”

She suffered the stroke early the next morning, the suit says.

“This has obviously been devastating to my mother,” said Tony Wooton, who has helped care for her since the stroke.

“The things most people take for granted, like opening a can of soup, she can’t do any more,” he said. “This isn’t about money. She’s mad and her life has changed completely, forever. She’s trying to make sure this doesn’t happen to anyone else.”

The lawsuit is the latest legal skirmish in a long-running battle over how HMOs deliver health care. Among the issues is whether front-line physicians in managed-care systems have incentives to withhold treatment because it takes money out of their pockets.

Hiepler said Wooton’s suit takes that a step further. It doesn’t name any front-line doctor as a defendant, but zeros in on managers who he contends make the ultimate medical decisions.

Michael D. Gonzalez, a Los Angeles lawyer who defends doctors and others in such lawsuits, said Hiepler is entering an evolving area of the law as it relates to managed health care.

“Mark has obviously tapped into a real groundswell of feeling about managed care and is running with it,” Gonzalez said. “Clearly he’s touched a nerve. But for the most part, this system works really well for most Californians.”

But the way Hiepler sees it, it’s a system with plenty of room for improvement. “Doctors have lost autonomy in dealing with patients,” he said. “Patient care is being second-guessed, and doctors are almost powerless in making health-care decisions. We have to make the law catch up with the practice of medicine.”