Ethical Challenges in Managed Care: A Casebook

By Karen Grandstrand Gervais; Reinhard Priester et al. | Go to book overview

6
Referral Practices Under Capitation

CASE STUDY

Mr. Carmen lived in a large gulf state city and had been an employee of Western Manufacturing, Inc. for many years. Western provided health care benefits to its employees by contracting with an HMO named Truman Health. Under the terms of the Truman Health policy, Mr. Carmen was required to select one of the HMO's authorized primary care physicians. This physician would act as a "gatekeeper" of Mr. Carmen's health care. In order to see a specialist and have the visit covered, Mr. Carmen would need to obtain a written referral from his primary care physician.

Mr. Carmen chose Dr. Albright as his primary care physician. He was a partner at the Parkside Family Medical Clinic and had been the family doctor for Mr. Carmen and his family for many years. At the outset of their relationship, Mr. Carmen informed Dr. Albright of a family history of heart disease and communicated his concern for his own health. Mr. Carmen's father had died of heart disease while in his mid-fifties, and his mother had died from conditions including heart disease while in her early sixties. Mr. Carmen's two half-brothers had both undergone coronary bypass surgery for heart disease in their early forties.

In February of 1993, Dr. Albright administered an echocardiogram and tested Mr. Carmen's cholesterol level. While the echocardiogram was normal, Mr. Carmen's cholesterol was significantly elevated. Mr. Carmen altered his diet, began exercising, and tried various medications to help control his cholesterol level. Over the course of the next three years, Mr. Carmen's cholesterol level continued to rise, and he began experiencing a tingling sensation and shortness of breath as well as intermittent dizzy spells. By the end of 1996, he was experiencing regular tightness in his chest, difficulty breathing, buzzing in his right ear, and continuous lower back pain.

Mr. Carmen and his wife visited Dr. Albright eleven times during this three-year period, repeatedly requesting a referral to a cardiologist. On each

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