Supreme court ruling on HMOs irks physicians.
"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 wrong-fully denied benefits by their respective health plans. One patient, Ruby Calad, sued Cigna Healthcare of Texas after she underwent a hysterectomy 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 (Naprosyn, Roche Pharmaceuticals) but allegedly suffered a severe reaction that required extensive treatment and hospitalization.
In their suits, Ms. Calad and Mr. Davila contended 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 (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, 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 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," Dr. Fleming said. "I understand there are people in Congress willing to bring it back."
BY JOYCE FRIEDEN
Associate Editor, Practice Trends