For almost a year, Emanuela Bassora blamed her husband's death on an incompetent doctor. Now, she's wondering whether a skilled doctor made bad decisions to save money for Humana Health Care Plans.
Despite nagging problems that wouldn't abate, she said, Emanuele Bassora's doctor prescribed simple remedies, such as cough syrup for a chronic cough and antibiotics for swollen glands. The 66-year-old man was told to diet to control his painfully distended belly, she said.
Finally, the Bassoras switched to a different doctor who prodded the sick man's stomach and X-rayed his lungs. Mrs. Bassora remembers what the doctor said: "My Lord, you're filled with water."
But it was too late to treat him effectively. Bassora died one month later from lymphatic cancer.
The couple had belonged to the Humana Gold Plus Plan, one of the private insurance companies that contract with the federal government to provide Medicare coverage to the disabled and elderly, and in the process save taxpayers billions of dollars.
In a landmark case working its way through Hillsborough Circuit Court, Humana is defending itself against accusations it forces primary care doctors to save money by withholding care to seriously ill patients, blocking access to specialists and delaying treatment.
Several plaintiffs claim their primary care doctors denied them access to specialists despite chronic complaints that later were diagnosed as cancer. One of the original plaintiffs has since died of the disease.
The case is being fought as a violation of state marketing laws, which require truthful advertising of HMOs, said Jonathan Alpert, the Tampa lawyer who represents the plaintiffs.
Dr. Jerry Reeves, senior vice president and chief medical officer for the company based in Louisville, Ky., this week defended the medical integrity of the plan, citing the company's 24-hour hot line and ease with which patients can switch doctors or call the company with complaints.
Certainly, Reeves said, it is better for Humana medically, ethically and financially to treat health problems quickly.
Some customers tell a different story. Coverage of the lawsuit has triggered dozens of calls to the Times from current and former Humana customers who described situations similar to those in the lawsuit, which in many cases ended in the death of a loved one. They said medical treatment was delayed or stopped for reasons they never could understand.
One woman said her dying mother was denied a wheelchair, and a leg wound went untreated. A 42-year-old quadriplegic in St. Petersburg said he couldn't get a wheelchair. A Tarpon Springs man wonders why his 79-year-old mother never saw a cardiologist for the heart problem that finally killed her.
Nancy Wilson knew her husband, Vernon, 68, a heavy smoker, was dying from chronic lung disease, so she was stunned when he was discharged in January from St. Petersburg Medical Center and sent to a rehabilitation center for physical therapy. She said Humana didn't consider him sick enough to be hospitalized. He died 48 hours later, she said.
"It's devastating. You try to tell these people he needs help. Something needs to be done. They look at you like you're a piece of tissue paper and they look right through you," she said.
Humana spokeswoman Pam Gadinsky said she is prevented by patient confidentiality laws from discussing individual cases, but she said there was "compelling" information in medical records that was inconsistent with recollections from some family members about treatment.
"Some of this doesn't pass the smell test," Reeves said. "It's inconsistent with the various programs we're doing."
However, confidential Humana documents contained in court files detail a system in which patients unknowingly could be sent to doctors under pressure to reduce costs by limiting referrals to specialists or hospitals.
In one document, primary care doctors are given conditions under which they can delay a specialist referral for up to two weeks even after diagnosing a patient's problem. Another document recommends doctors clear specialist referrals with a Humana medical director before telling the patient they should see a specialist. Other documents provide details of how patients treated by doctors who send more than 25 percent of their patients to the hospital become targeted for tougher admitting standards.
Sara Rosenbaum, a national authority on managed care and professor at the George Washington University School of Public Health and Health Services, reviewed Humana's secret provider agreements for the plaintiffs and concluded the company set up a "radical" system to limit per-patient payments.
According to records gathered for the lawsuit, doctors who signed on with Humana became mini-insurers, absorbing an unusually high amount of risk for a small pool of patients and ultimately being forced to go into debt or withhold care to make money.
The lawsuit was declared a class action last month, which means technically it represents the interests of more than 250,000 Humana Gold Plus Plan customers who were enrolled before Jan. 1, 1997.
Advocates for the elderly say the lawsuit speaks to ongoing flaws in the relatively new area of Medicare managed care that may only worsen in the next year as fallout from the Balanced Budget Act forces more people into private Medicare programs.
Joyce Dubow, a senior policy adviser with the American Association of Retired Persons, said her organization is pushing at state levels for ombudsmen to advocate for Medicare clients, some of whom are too frail or too intimidated by doctors to challenge the managed care system and fight for their medical care.
"It's difficult to know if the guy who didn't do anything about that distended abdomen is a lousy doctor, or if he's lousy because of the financial incentives he didn't have before," Dubow said. "In general, protections are in place for Medicare beneficiaries, but it takes very vigilant oversight to make sure plans are behaving properly."
Health care analysts say there will be problems as long as quality assurance programs are run without external oversight.
Alpert said it's difficult for the survivors of elderly patients who die to sue for wrongful death.
"The wrongful death act is structured so you can kill an old person for free," he said.
Complicating the issues is the attitude of many older Americans, particularly lower-income people, who would not dream of questioning their doctor's decisions.
Gayland Swaim, a 78-year-old New Port Richey man, was told last year by his primary care doctor that his carotid arteries were blocked, but he said he was not told he needed immediate treatment. He suffered a stroke two days later. It never occurred to him to request anything from his doctor. "I figure he's knowing what he's doing, and I don't," Swaim said.