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Supreme Court decision on HMOs irks physicians.

The Supreme Court's recent ruling that patients cannot sue their health maintenance organizations will be detrimental to patients, according to according to
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

 leaders from several physician organizations.

"It is a bad thing for patients," said Dr. Michael Fleming, president of the American Academy of Family Physicians. "Frankly, HMOs need to be held responsible, just as I'm held responsible as a physician if I make a decision."

The Supreme Court case, known as Aetna Health Inc. v. Davila, involved two Texas patients who claimed they were wrongfully denied benefits by their respective health plans.

One patient, Ruby Calad, sued Cigna Healthcare of Texas after she underwent a hysterectomy hysterectomy (hĭstərĕk`təmē), surgical removal of the uterus. A hysterectomy may involve removal of the uterus only or additional removal of the cervix (base of the uterus), fallopian tubes (salpingectomy), and ovaries  and the plan's discharge nurse said Ms. Calad did not meet the criteria for an extended hospital stay, even though her physician had recommended it. Ms. Calad was discharged but suffered complications and was readmitted to the hospital. Her suit alleges that these complications would not have occurred had Cigna approved coverage for the longer stay.

The second case involved Juan Davila, whose physician recommended rofecoxib (Vioxx, Merck & Co. Inc.) to treat Mr. Davila's arthritis. Aetna, Mr. Davila's health plan, refused to pay for Vioxx. Mr. Davila began taking naproxen naproxen and naproxen sodium, potent nonsteroidal anti-inflammatory drugs (NSAID) used to alleviate the minor pain of arthritis, menstruation, headaches, and the like, and to reduce fever.  (Naprosyn, Roche Pharmaceuticals) but allegedly suffered a severe reaction that required extensive treatment and hospitalization.

In their suits, Ms. Calad and Mr. Davila claimed that a 1997 Texas law known as the Texas Health Care Liability Act prohibited the plans from improperly denying needed medical care. But the health plans countered that the Texas law was preempted by the federal Employee Retirement Income Security Act The Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C.A. § 1001 et seq. (1974), is a federal law that sets minimum standards for most voluntarily established Pension and health plans in private industry to provide protection for individuals enrolled in these plans.  (ERISA See Employee Retirement Income Security Act.


See Employee Retirement Income Security Act (ERISA).
), which governs multistate health plans.

Unlike the Texas law, which allows patients to collect monetary damages for injuries caused by denied coverage, ERISA limits damages to the actual care that was improperly denied. The Supreme Court, in a unanimous ruling, agreed with the health plans that ERISA prevailed in both cases.

"This decision eliminates state legal accountability for managed care plans that alter, delay, or deny a physician-recommended course of treatment," Dr. John Nelson, president of the American Medical Association, said in a statement. "Now patients' only recourse is through the federal courts, where they cannot receive damages for harm caused by denial of treatment--only for the value of the benefit denied."

Dr. Jane Orient, executive director of the Association of American Physicians and Surgeons The Association of American Physicians and Surgeons (AAPS) is a politically conservative association of physicians, medical professionals and students, patients and others,[1] founded in 1943. , had a different opinion on the decision. "HMOs really aren't insurance but [instead are] a way of prepaying for medical care," she said in a statement. "That means the medical care that the HMO HMO health maintenance organization.

A corporation that is financed by insurance premiums and has member physicians and professional staff who provide curative and preventive medicine within certain financial,
 determines to be reasonable and necessary, not all the medical care that is possible, desirable, or even life saving. The Supreme Court decision shows that the courts are not going to intervene in this matter."

She added, "Managed care by its very nature places physicians in a conflict-of-interest situation with patients. Physicians should not be a party to it."

The American Academy of Family Physicians' Dr. Fleming noted that the Supreme Court "didn't have much choice" in making its decision, since the court's job was just to rule on whether the claims fell under ERISA. He said that he was hopeful that Congress would reconsider a "patient's bill of rights" law that would allow patients to collect damages from health plans.

"We've strongly supported a patient's bill of rights before, and I'm sure if that gets brought back up, we'll support it again. I understand there are people in Congress willing to bring it back."


Associate Editor, Practice Trends
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Title Annotation:health maintenance organizations
Author:Frieden, Joyce
Publication:Internal Medicine News
Geographic Code:1USA
Date:Aug 1, 2004
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