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Lawsuit challenges Humana HMO's practices

A lawsuit seeking class-action status was filed Tuesday in Hillsborough County civil court against Humana Health Care's Gold Plus Plan, the largest Medicare HMO in the state.

The suit alleges that two Tampa men suffering from prostate problems did not get needed referrals from Humana to urologists; it turned out that both had prostate cancer.

The problem, the suit says, is that Humana doesn't tell members about its physician contracts, which allegedly discourage doctors from making referrals to specialists. The lawsuit also alleges that Humana forbids its doctors from discussing certain treatment options with patients.

The suit estimates that thousands of Medicare recipients may have signed up for Humana's HMO without being aware of such HMO-physician relationships.

It is believed to be the first attempt at a class-action suit against a managed health-care plan. But the attorney filing the suit, Jonathan Alpert of Tampa, is no stranger to such litigation.

Though this is his first action against an HMO, Alpert has a national reputation for filing lawsuits against major banks and their securities divisions, including Barnett Banks Inc., AmSouth Bancorporation, First Union and NationsBank.

Primary care physicians are typically paid a set fee per member by the HMO, regardless of the number of times they see the patient. Under some contracts, the primary physician also picks up the tab for any specialist care.

According to the lawsuit, such arrangements meant the plaintiffs were unable to get timely treatment for prostate cancer.

A spokesman for Humana, which has operated a Medicare HMO in Florida since 1987, said the insurer had not yet received notice of the court action Tuesday afternoon, but typically would not comment on pending lawsuits.

According to the suit, Lorenzo Ruiz and Israel Castillo, both Humana members, were refused referrals to urologists for treatment of what ultimately was diagnosed as prostate cancer.

Ruiz, 73, visited his Humana physician in 1990 with a complaint of pain in the mid- to lower abdomen. He was given a clean bill of health and refused a referral. Within the same week, Ruiz attended a free prostate cancer screening at a local hospital, where the doctor recommended he see a urologist and wrote a note to the Humana physician urging he make a referral.

The Humana doctor then sent Ruiz to a urologist, who diagnosed cancer and recommended radiation therapy. The cancer is in remission.

Castillo, 69, first sought treatment for prostate pain from his primary-care physician in January 1996. Though his pain continued, Castillo was repeatedly denied a referral. In summer 1996, Castillo canceled his Humana HMO membership and joined another health-care plan. He immediately was referred to a specialist and diagnosed with prostate cancer, which now is in remission.

The two met last summer when Ruiz became a customer of Castillo's insurance agency in Tampa.

"We started talking about our problems, which were so similar, and we decided to go fight Humana," said Castillo. "In my business, I've heard of many people who go through the same thing. I think we will hear from them now that the suit has been filed."

Charles Inlander, president of People's Medical Society, a consumer watchdog group in Allentown, Pa., said the confidential nature of medical problems has effectively discouraged class-action lawsuits against HMOs, despite a high volume of individual complaints.

"There are a tremendous number of complaints and appeals that go on every day in almost every managed-care plan in terms of referrals," Inlander said. "But most people don't know another person has been denied."

Inlander said the lawsuit targets a key issue for HMO enrollees.

"If you don't know what a doctor's incentive is, you don't know if you're getting the best level of care," said Inlander. "And if HMOs don't reveal that information, then consumers are choosing managed care in the dark."

Alpert said his clients would not have enrolled in Humana if they had been aware of the arrangements between the HMO and its physicians.

"If these people had been told, "Your medical care is going to be rationed, join the HMO at your own risk,' they would have made a knowing decision," said Alpert.

"Instead, they were told they'd get all the medical care they needed. They weren't told about the sticks and carrots used on doctors to prevent patients from getting medical treatment."

Although the lawsuit does not specify damages, Alpert said he wants the court to order Humana to repay the premiums paid by the plaintiffs, which averaged about $40 per month.

As a Medicare HMO, Humana Gold Plus also receives a monthly reimbursement from the federal government. That amount varies according to geographic area.

Humana's Medicare HMO in Florida, which has about 220,000 members, received $1.1-billion in member and government premiums in 1995. According to Alpert, Humana's Medicare premiums from Tampa Bay enrollees and the government totaled $380-million in 1996.

"We hope this lawsuit will promote public discussion of whether we're going to be rationing health care, what that means for senior citizens and what it means as the generation of baby boomers gets older," Alpert said.

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