Legal Eagle Eye Newsletter for the Nursing Profession (7)1 Jan 99
Quick Summary: When an HMO interjects itself into medical decisions affecting a subscriber’s care, the HMO must make decisions in a medically reasonable manner.
A health maintenance organization’s (HMO’s) motivation in containing healthcare costs is praiseworthy. However, when an HMO’s decision limits a subscriber’s access to treatment, the court must view that decision as a professional judgment.
This HMO provided a phone service for emergent care staffed by triage nurses. The HMO is responsible for inadequate assessment and negligent advice given by those nurses.
Where an HMO is providing health care services rather than merely paying for services, the HMO’s conduct should be judged the same as a hospital or other health care provider.
The staff of an HMO do not practice medicine themselves, but their decisions limiting hospital stays, restricting the use of specialists, prohibiting or limiting post-hospital care, etc., directly affect their subscribers well-being.
SUPERIOR COURT OF PENNSYLVANIA, 1998.
The patient belonged to a health maintenance organization (HMO) when she became pregnant with her first child. She was given the choice among six physicians as her primary prenatal care provider, and chose one of them.
Her HMO membership card instructed her to contact either her chosen primary care physician or the HMO itself if she had questions about her health care. If a subscriber contacted the HMO directly, the subscriber would speak with a telephone triage line staffed by registered nurses employed by the HMO.
She saw her physician frequently for abdominal pain and back pain. She was seen in his office on three consecutive days for these complaints. The next day she could not reach her physician so she called the HMO.
A nurse listened only very briefly, then simply told her to call her physician. The next two days the same thing happened. None of the nurses knew her history or listened long enough to find out she was in the fifth month of a difficult pregnancy.
When she called the HMO a fourth time, complaining of back pain, someone at the HMO put her on the phone with an in-house orthopedic physician-consultant. He told her to drive to the emergency room at a hospital one hour away, father from her home than three other hospitals. At that hospital they treated her as an orthopedic patient, as her complaints to her HMO of back pain were what got her referred there, but they did allow her to go to the labor and delivery floor for a check-up.
On the labor and delivery floor it was realized she had been having pre-term labor. A few hours later the patient delivered a small pre-term infant, who died.
The Superior Court of Pennsylvania permitted her and her husband’s lawsuit to proceed against the HMO, categorizing the HMO as a healthcare provider in its own right and judging it, unfavorably, under the law of professional malpractice. Shannon v. McNulty, 718 A. 2d 828 (Pa. Super., 1998).