It seems downright un-American for a medical professional to face the loss of his livelihood with no explanation and no opportunity to defend himself. So a ruling by the California Supreme Court favoring OB/GYN Louis Potvin, M.D., who was terminated without cause by insurer Met Life, probably could have been expected.
But the resolution of this matter is far from simple. What appears to be a just victory for an individual physician may, in fact, mean headaches for medical groups in California.
The court, in a 4-3 decision, found California's peer review statute had been circumvented and sent the Potvin case back to trial court for adjudication. Since Potvin died after the case was filed, the matter is being pursued by his estate. But even without that complication, a number of thorny issues need to be addressed.
At stake is an issue that affects any medical organization that accepts risk and attempts to manage the way care is delivered. For all those who are toiling to deliver better, more efficient care, the bottom line is clear: A businesslike operation must protect the interests of patients and fairly treat the practicing physicians.
At the same time, such organizations need the ability to determine who should be part of their network and who isn't cut out for their way of operating. Such groups require physicians who are committed to the organization's protocols and, instead of signing deals with many different payers, are willing to focus most of their efforts in one or two medical networks.
A physician is unlikely to make that commitment if he feels he risks a future arbitrary decision that it's necessary to streamline the provider panel. For that matter, a medical group would need to use discretion in getting rid of a partner because he no longer fit into the organization's vision.
California's highest court has pointed to the need for risk-taking organizations to recognize how their contractual relationships can make or break a physician's access to patients. Under the ruling, a hearing may be in order for any physician whose contract expires and is simply not renewed by an IPA, hospital, medical group or other contracting organization.
Failure to achieve the right balance between the needs of individual physicians and the medical practice could spark a wave of litigation, forcing California groups already on the financial edge to pay dearly to defend themselves each time they reconfigure their organizations.