A doctor’s primary professional obligation is to his or her patients, not to the patients’ insurance companies. It’s one thing for an insurer to encourage doctors to refer patients to other physicians in its network as a way to control costs, but quite another for it to require those doctors to emphasize financial concerns.

The Hawaii Medical Service Association, the largest health insurer in the state, seems to have crossed that line with a new contract it has imposed on its participating physicians, doctors who accept HMSA’s determination of eligible charges as full payment for medical services rendered and who have little choice but to accede to HMSA’s demands given the nonprofit’s dominance in the Hawaii market.

The Hawaii Medical Association, a professional organization that advocates on behalf of its 1,100 physician-members statewide, is correct to push back against HMSA’s intrusion on the doctor-patient relationship. The insurer should revise its latest contract in consideration of the doctors’ legitimate concerns; there are roughly 2,800 doctors in the HMSA network.

At issue is a new contractual clause that urges physicians to refer patients covered by HMSA insurance to other HMSA-participating doctors if those patients need specialized care, and, more onerously, requires doctors who refer patients to non-participating physicians to warn those patients that they may face higher out-of-pocket expenses as a result.

"The first obligation a doctor has is not to the insurance company; it’s to the patient. I’m going to send my patient to the specialist I consider the best in that field. It is not the doctor’s function to explain it may cost them more," said Dr. Malcolm Ing, among those who objects to the new rule. "In fact, it may cost them less. Who knows? … I’m not going to tell a patient in the second breath it may cost them more because I’m referring out of network."

The new policy essentially discourages doctors from referring patients to specialists outside the HMSA network, and may dissuade patients from making optimal health care decisions about specialized care. It represents an economic intrusion into what should be a wholly medical decision. Physicians have a duty to refer patients to the specialists they believe can best treat the patient’s medical condition.

It’s perfectly reasonable that patients generally will prefer qualified specialists within their own insurance networks, anticipating lower costs, and that doctors should let patients know when they are making an out-of-network referral. But to enshrine that as a formal contractual obligation puts too much of the burden on the doctor, who should be primarily focused on medical decisions — not keeping track of the latest HMSA participating-physician directory.

The insurance company itself can help keep patients apprised of which doctors are in its network, via mailers and online information. The patients and their families also bear some responsibility to ask whether the specialists to which they are referred are part of their insurance network, especially if out-of-pocket expenses are of major concern. Doctors should not withhold this information when they know it, but neither should they shoulder the burden of discovering and conveying it.

By transforming what should be common-sense conversations into contractual dictates, HMSA has intruded on decisions best left to medical judgment. It’s a surprising stance, frankly, for an insurance company that markets itself as offering patients among the widest choice in medical providers.

Just because this clause exists in the latest contract, does not mean it is cast in stone. HMSA should delete this new rule, for the good of the doctors it depends on and the patients it serves.