Some HMOs are jeopardizing patients' safety with "mass production" medicine, the Florida Board of Medicine declared Saturday. Doctors who work at assembly-line clinics are forced to see patients at such a fast pace that they make mistakes, board members said.
In addition, they said, some health maintenance organizations (HMOs) pressure doctors to cut costs to the point that it affects their professional judgment.
"The board has uncovered an obvious problem where the consumer is not protected," said Dr. Fuad Ashkar, one of its members. "The public is at serious risk if we don't do anything about it."
Board members did not specify which HMOs they meant, other than Humana.
Their frustrations erupted in a case involving a doctor at a Pasco County Humana clinic who misdiagnosed a heart attack as a muscle strain. They said Dr. Hasan Zeya is a good doctor who fouled up because he was overwhelmed with patients.
"I'm sympathetic," board member Dr. Louis C. Murray told Zeya. "You've described a setting in which no one could practice quality medicine."
At for-profit HMOs and walk-in clinics, "you get entrepreneurs calling the shots for the doctors," said Bruce Lamb, attorney for the state Department of Professional Regulation (DPR).
"Really nobody regulates them," he said. Although the DPR checks out complaints against against individual doctors, he said, "we don't have authority to launch investigations of these clinics."
The chairman of the medical board, Dr. Zachariah P. Zachariah, announced that he will appoint a committee to hold public hearings on the issue soon.
In the meantime, board members said, doctors should tell their HMO bosses that they will not shortchange patients _ even if it costs them their jobs. The alternative may be losing their medical licenses.
"He may be captured by an industry that's exploiting his services, but it's not the industry that's licensed, it's (the doctor) that's licensed," said Dr. J. Lee Dockery, a board member.
The Department of Professional Regulation tried to gain authority to investigate HMOs four years ago but could not find a legislative sponsor, attorney Lamb said.
HMOs are licensed through the state Department of Insurance. But that agency has jurisdiction only over financial disputes and enrollment problems.
The state Department of Health and Rehabilitative Services (HRS) comes closest to having authority over quality of care. This year it got legislative authority to beef up enforcement, but it is unclear whether HRS has the power, say, to set a cap on the number of patients per doctor.
DPR Secretary George Stuart, who attended Saturday's meeting of the medical board, said the HMO problem will require attention and cooperation from all three agencies. A new statewide health commission may be able to play a role, he said, once Gov. Lawton Chiles appoints the members.
HMOs charge members a set fee each month and promise a full range of medical services whenever they're needed. But members must receive the care from their HMO or pay for it themselves.
With health-care costs rising faster than membership fees, some HMOs are placing doctors in ethical dilemmas, board members said. One problem is that doctors have to see more patients than they can handle. Another source of pressure is from administrators, who want doctors to cut back on costly tests and delay treatments.
"I understand the economic pressures on doctors," Stuart said. "But they have an obligation to carry out their professional duties. It does not excuse them."
Zeya, the doctor whose case the board considered, works on salary at Bay Point Medical Center in Port Richey, which is owned by Dr. William Young. Zeya also has an office in Tampa where he sees private patients on Saturdays.
Young, who owns another Pasco clinic, contracts with Humana to provide care for many elderly HMO members. Zeya said Bay Point clinic also treats non-HMO patients.
In April 1989, a 70-year-old patient identified by his initials, J. B., came to the clinic feeling poorly after a sleepless night of chest and shoulder pain. He said Zeya did nothing but talk to him briefly and listen to his chest with a stethoscope.
After J. B. spoke of rowing a boat the week before, Zeya decided the problem must be muscle strain. He advised him to take aspirin and to call Zeya's private office in Tampa to schedule tests a week later.
J. B. walked out feeling just as bad as when he went in. He decided he couldn't wait a week, so he went to another clinic, Gulf Coast Medical Center. A doctor there ran tests, including an electrocardiogram (EKG), and told J. B. he had had a heart attack.
J. B. was hospitalized at Bayonet Point, then flown by helicopter to Tampa General for triple bypass heart surgery. As of February, when depositions were taken in the Zeya case, he was doing fine.
Zeya said he missed the heart attack partly because J. B. understated his symptoms. But Zeya also conceded that he was rushing to fit in J. B. because the clinic requires him to treat 600 patients a month _ most of them sick and old, with multiple problems.
"How could I end up giving this patient just aspirin?" he reflected. "Such a thing could have happened only in these kinds of circumstances.
"If I'd had a respectable amount of time to spend with the patient," he said, "this would not have happened."
The caseload for each Humana HMO doctor is 1,100 patients, Zeya said.
"Who is the guy who assigns 1,100 patients to each doctor?" board member Murray asked.
"You should ask this question to Humana," Zeya replied. "They are the ones assigning patients."
"Have you ever told Humana it's too many and it's not possible to give good care?" board member Gilbert Rodriguez asked.
"Yes, of course," Zeya said. "We have told them time after time."
Humana's Tampa Bay spokeswoman, Pat Driscoll-Kneeland, said late Saturday by telephone that she didn't have statistics available at home to tell how many patients were assigned to Zeya's center.
However, she said, Humana considers the size of the staff, the amount of space and type of equipment at a center before assigning more patients.
"We review these centers regularly to make sure there are not more patients assigned . . . than our standards call for," she said.
Zeya's penalty, the board decided, should be a $2,000 fine, a reprimand, classes including an ethics course, and two years' probation with another doctor checking on him.
That monitoring physician must evaluate 20 percent of Zeya's medical records each month.
Zeya protested that that would add up to 120. It would be impossible to find any doctor willing to take on such a chore, he said.
Board members sympathized, but said they could not bend their usual procedures.
Some members wanted to impose a limit on Zeya of 300 cases a month, but relented when the doctor said that probably would cost him his job.
Zeya has a week to decide whether to accept the board's penalty or seek a formal hearing through the state Department of Administration.
Cases of poor care at HMOs have been coming before the medical board for years. But the others involved bad doctors.
Zeya's case touched a nerve because he seems to be a good doctor brought down by a bad system, board members said.
"If this kind of practice continues," said Ashkar, "we're going to have a lot of good doctors up here because they can't cope. Something definitive must be done."
_ Times researcher Lorraine Tonna contributed to this report.