What's next........ HMOs Win Supreme Court Malpractice Case June 21, 2004 07:11 PM EDT WASHINGTON - Patients can't seek fat damage awards in court if their HMOs refuse to pay for doctor-recommended medical care, the Supreme Court ruled Monday, rejecting arguments that the threat of multimillion-dollar lawsuits keeps insurance companies honest. The unanimous decision invalidated an important part of patient rights laws in several states and tossed a political hot potato back to Congress. Lawmakers have tried repeatedly and failed to pass national patient protections. The last and most promising effort foundered on a wronged patient's right to sue. Health insurers argued to Congress and again in the Supreme Court that enormous jury awards drive up the cost of health care for everyone and might lead some employers to drop their health plans. The court said HMOs are shielded from lawsuits in state courts, where juries are more apt to side with victims and order up multimillion-dollar judgments from insurance companies. Relying on a federal pension benefit law that predates the rise of managed care, the court said patients may pursue claims only in federal courts. There, awards are capped at only the cost of medical services the HMO would not cover. The ruling affects the roughly 72 million people covered by HMOs. It applies to a gray area of medicine and insurance, in which decisions about what treatment to pursue and what coverage to offer are mingled. The situation arises frequently in managed care, where doctors belong to a closed network overseen by administrators, who may not be doctors but who nonetheless decide what the company will pay for. "By reserving the right to decide what is - and what is not - medically necessary, managed care plans can now practice medicine without a license, and without the same accountability that physicians face every day," the American Medical Association said afterward. Democrats on Capitol Hill also denounced the ruling, and presumptive Democratic presidential nominee Sen. John Kerry said he will make it a campaign issue against President Bush. The justices rejected lawsuits filed by two Texas patients who claimed they suffered avoidable pain and complications because their HMOs pinched pennies. They brought suits under a Texas patients' rights law passed when Bush was governor. During the 2000 presidential contest, Bush took credit for the law. When the issue reached the Supreme Court, however, the Bush administration sided with insurers. Juan Davila, who sued Aetna Healthcare under the Texas patients rights law, took what he claims was inferior pain medication instead of the Vioxx his doctor had recommended because Aetna Health would not pay for the more expensive drug right away. The cheaper medication caused bleeding ulcers, and he almost had a heart attack, Davila said. "My life is not the same and may have been cut short because of the HMO's decision to play doctor," said Davila, a post-polio patient. The Supreme Court heard his case alongside that of hysterectomy patient Ruby Calad, who claimed that Cigna Healthcare of Texas turned her out of a Houston hospital after only one day of recovery. The HMO would not pay for a longer stay, even though her doctor recommended it. She was back in the emergency room a few days later, suffering complications she claims could have been avoided had she remained hospitalized longer after surgery. The Supreme Court did not decide whether Davila and Calad deserved better, only whether and where they could sue. Insurers and business groups had argued that the 1974 Employee Retirement Income Security Act, or ERISA, trumps state patient protection laws that would allow patients to sue over allegedly negligent coverage decisions. ERISA was supposed to protect worker benefits while guaranteeing employers uniform national rules and a streamlined process of handling lawsuits or complaints. Calad and Davila could have brought their lawsuit under ERISA's rules but chose not to, Justice Clarence Thomas wrote for the court. Their lawsuits "are completely pre-empted by ERISA," he said. In a statement after the ruling, Aetna called it a "reaffirmation of the law applicable to employer-sponsored health plans." "By affirming the role of ERISA in employee benefits the court has helped to assure that millions of working Americans will continue to have access to quality health coverage provided by their employers," the insurer said. At least nine other states have laws similar to the Texas statute: Arizona, California, Georgia, Louisiana, Maine, New Jersey, Oklahoma, Washington and West Virginia. The cases are Aetna Health Inc. v. Davila, 02-1845 and Cigna Healthcare of Texas Inc. v. Calad, 03-83. --- On the Net: The ruling in Aetna v. Davila: http://wid.ap.org/documents/scotus/040621aetna.pdf
Yeah, this is big. It'll look good to many people, keeping costs and premiums down, etc., until it's someone in their family that gets denied some medical benefit. Maybe it shouldn't surprise me, after all, it is money that makes the world go 'round. Unfortunately. Jack
Well I am very mixed on this subject. Whenever I start feeling like this decision is BAD for people, my thoughts return to those brothers Virgil and John in Staten Island in 1992. They jumped off a City-made pier and both of them broke their necks. Mind you that they had to scale a 3-foot, wooden-slat fence to do it and look down at the shallow water about 10 feet below the pier. They misjudged it and admitedly state that they "should have been more careful." Due to this, they sued NY CIty for $104 million dollars and WON!! (it was "reduced" later on to only $25 million). The basis of the case was that there were NOT ENOUGH no diving signs off the pier. If the state government would have put up the pier (vs the City of New York), the damages would have been greatly limited. I also recently read in the local newpaper that New York City last year paid about $500 million in claims. In 1978, the total was just $21.4 million. This is truly a sad commentary on our litigous society. Well, wanted to add my $0.02. Hot coffee from McDonalds anyone? peACE, ACE
Well, it already has happened in my family, my cousin can not afford to have an operation because her insurance company does not want to pay for it! I'm not sure of the reason why they won't pay for it, but why do we pay our insurance premiums and then they do not want to give us the medical benifits that we pay for? As my grandmother would say, money does not just talk, it SCREAMS!! Rich Hartel
Hello Rich, I am sorry to hear that about your cousin - that situation is all too common and unfortunately problematic. My solution would not include lawsuits but rather make it "mandatory" for insurance companies to pay for recommended services by one's primary care physician along with a second opinion on some operations (procedures). Finally, once the patient has 2 opinions (both concurring) then the insurance would need to "fund" the procedure. If each doctor disagreed, then the there needs to be a third for a tie-breaker. It is also sad that the HMOs (at least in NY) - Blue Choice for example are PROFITING MILLIONS every year. peACE, ACE
To Ace, I agree with everything you said, but I don't see that happening anytime soon!! As the saying goes, why do the right thing, especially toward the paying customer! Rich Hartel
What about H.I.P. and these other HMO's that agressively solicit senior citizens into signing up with them????
Gina, I am not sure what H.I.P is. Please inform me . I work primarily with children and their families. I also notice that you are from NY - the insurance climate is very different depending on the region(s) one practices in. peACE, ACE
From a bioethics/medical ethics perspective you can only expect that the current situation will get worse. Scenario: There is a scientific/medical breakthrough that allows people to select the IQ of their unborn child. This procedure is not covered by insurance and so, as the saying goes, "the rich get richer and ther poor get pooer." Should this be allowed? How about if the issue was cancer? Hemophilia? Diabetes? Make no mistake, this is going to happen. Are you going to stop medical progress? Will you insist on equal benefits for all? While these may not be our problems to solve, they will belong to our children. Jack
