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Physician Incentives Make Americans Anxious


On August 19, 1996, Reuters reported that according to the American Medical News the case of Gross versus PruCare will be heard in Oklahoma City later this month.

The patient, David Gross, alleges that due to repeated denials of requests for a referral for an MRI or neurosurgeon that he "suffered a permanent spinal injury after PruCare physicians failed to diagnose a disc infection as it raged over a nine-month period during 1993." Robert E. Manchester, Gross's attorney, asserts that bonus arrangements in place at PruCare influenced the refusal of care.

Mr. Gross finally received authorization for care after going to the emergency room with "unbearable pain." The MRI revealed "..Gross's disc space infection obliterated an entire disc and damaged the adjacent vertebrae."

According to the article in American Medical News PruCare contends that "it's pre-empted from the suit by ERISA, that it's protected from vicarious liability for doctor actions under state law, and that it lived up to its contractual obligations by promptly paying all of Gross's medical bills." Since Gross was a state employee, the ERISA claim does not apply according the article.

The American Medical News further reported that capitation agreements are increasing anxieties about the quality of health care delivery. "One third of all physicians have capitated commercial contracts, while 48% are subject to some form of financial withhold."

Chair of AMA board of trustees, Dr. Nancy W. Dickey, remarked, "The more a physician's income can be impacted either up or down by a particular patient care decision, the more likely that fiscal or financial incentive is to change that actual decision." Full disclosure of financial agreement to patients is advocated by the AMA.


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