DAILY MAIL HEALTH REPORTER
A doctor can elude discipline by the state Board of Medicine whenhe blunders - if he is the medical director of a managed carecompany and holds no license in West Virginia. So, the medicalboard, whose job is to protect patients, is asking the Legislatureto adopt a law to require medical directors of such companies hereto be licensed locally.
'The Board of Medicine has no supervision or control overphysicians not licensed,' said Dr. S. Kenneth Wolfe, a member of theboard from Huntington, noting that without such recourse, a patienthas no mechanism for filing a complaint.
However, managed care officials generally criticize such a move,saying because their medical directors don't actually practicemedicine, they don't need to be licensed.
Rather, medical directors merely interpret nationally recognizedclinical protocols, said Teddy Cheatham, CEO of Carelink HealthPlans Inc.
Carelink, formerly owned by Camcare, insures more than 77,000West Virginians.
The issue has provoked controversy across the country. Currently,17 states require licensure in the states where health plansoperate. Nine require medical directors to be licensed in at leastone state, according to the Federation of State Medical Boards.
In West Virginia, medical directors in three of five managed carecompanies hold state licenses. However, one of the companies with anunlicensed physician director - Advantage Health Plan - is going outof business in the state as of the end of 2000.
Many practicing physicians contend medical directors do indeedpractice medicine, by substituting their judgment for that of thepatient's personal doctor.
Dr. Phillip Mathias, a Glen Dale ear, nose and throat specialist,said health maintenance organizations (HMOs) tell him how to do hisjob.
'They say they are not practicing medicine,' said Mathias, also amember of the medical board. 'But when you tell a doctor you can orcannot do something, that's what it is. I've had denials. I'vegotten so mad, they've threatened to kick me out of the HMO.
'If they want to kick me out, go right ahead. They won't. Theyknow all I want is what is right for the patient.'
What also is at issue, but what only a few will discuss, is thatHMOs, especially smaller ones, encounter difficulty even findingphysician directors. They say doctors command high salaries, oftenhigher than the company CEO.
Another issue is one of control. Doctors in general resentmanaged care, contending it transfers decision-making to insuranceemployees, untrained in the complexities of medicine.
The federation recommends that state boards pursue local lawsrequiring licensure. In a 1998 policy, federation officials wrote,'State medical boards must, through legislative or regulatoryprocess, require that MCO (managed care organization) medicaldirectors hold current and unrestricted medical licenses in thestates in which the patients of the plan reside.'
For two years, state Insurance Commissioner Hanley Clark hasactively opposed such legislation.
'There are protections in the system for the consumer,' Clarksaid, noting that the state's consumer protection law is among thebest in the country.
If a treatment is denied, a patient may appeal the decision tothe HMO, then to Clark. Also, HMOs undergo annual evaluations.Quality of care is considered very important, Clark said.
'There have been complaints and appeals brought to thisdepartment,' Clark said. 'But the vast majority of those have beenappealed because the procedure requested by the physician is notcovered by the policy.'
Clark said there's also fear that the medical board will revokethe license of an HMO doctor who doesn't cooperate or who isemployed by a plan physicians generally dislike.
Losing a medical license in one state could jeopardize licensurein all other states.
'It could destroy someone's life,' Clark said.
The Health Plan of the Upper Ohio Valley, which employs twophysicians licensed in West Virginia, opposes making it mandatorythat medical directors be licensed in all states served by the plan.
The health plan, based in St. Clairsville, Ohio, is WestVirginia's second largest HMO, with about 64,000 members.
'Medical directors are not considered to practice medicine,' saidchief executive officer Phil Wright.
On the other hand, officials at Super Blue HMO, part of MountainState Blue Cross Blue Shield, said there's probably some merit tolicensing medical directors, 'If for no other reason than to ensurethe medical director is familiar with state requirements,' saidspokesman Carl Callison.
However, last week, a U.S. district judge ruled that the TexasState Board of Medical Examiners may not discipline the medicaldirector of an HMO for his decision to deny home health care to a 13-year-old patient.
The court said the director made a coverage decision rather thana treatment decision, the Dallas Morning News reported.
The case involved the first suspension of an HMO medical directorin the United States by a medical board.
But the court failed to answer whether the federal EmploymentRetirement Income and Security Act - which applies to coveragedecisions - pre-empts the regulation of HMO physicians who makemedical decisions, said Texas Attorney General John Cornyn.
Meanwhile, the West Virginia Board of Medicine again will asklegislators to pass a bill mandating that medical directors of HMOsbe licensed in West Virginia. The licensure process takes a minimumof a month.
Board officials are asking patients to notify them in writing ifa decision by a medical director of a managed care company hasresulted in an adverse outcome. The board's address is 101 DeeDrive, Charleston, W.Va., 25311.
For a copy of the federation's report on managed care, call (817)868-4000 or go to the Web site www.fsmb.org. Click on policydocuments.
Writer Therese Smith Cox can be reached at 348-4874 or by e-mailat therese@dailymail.com.
