WEB
EXTRA!
WEB EXTRA! AAFP, others
push patient safety bill BY J. MICHAEL BRODIE
A recent Supreme Court ruling on lawsuits and HMOs could reignite congressional conversation about long-dormant patients' rights legislation. That could be the only plus to an otherwise dismal ruling, one Academy leader suggested.
The high court's unanimous June 21 ruling found that the Employee Retirement Income Security Act pre-empted state laws that permit patients to sue HMOs when the refusal to pay for treatment allegedly results in death or injury. As a result of the ruling, patients can seek redress only in federal courts.
"The Supreme Court's decision is disappointing but not surprising," said AAFP Board Chair James Martin, M.D., of San Antonio.
The cases -- Aetna v. Davila and Cigna Healthcare v. Calad -- involved the Texas Health Care Liability Act, adopted in 1997. The act made employer-paid health insurance plans liable for negligence when they wrongfully refused to pay for medical care.
The court backed the insurance industry's contention that coverage determinations are strictly decisions over what a given plan will and will not fund, not whether the patient deserves the care. The Bush administration took a similar position in its arguments before the court. Congress passed ERISA in 1974 to encourage the formation of employee benefit plans by subjecting them to federal regulation rather than the rules of individual states.
"Our hope had been that, rather than just upholding current law, the court would have supported the concept that current ERISA law does not adequately address the issues of health care," Martin said. "We hoped this would encourage the development of a new national set of legal health care guidelines."
Martin said that, before the ruling, HMOs in Texas were compelled to fulfill contractual agreements regarding care. "They recognized that refusal or denial of agreed-upon contractual services and subsequent poor outcomes would result in substantial penalty to them," he said. "As a result of this decision, the patients and physicians of this country will need to be vigilant regarding future decisions from these organizations."
Martin predicted the court's ruling would probably prompt members of Congress to introduce new patient protection bills.
In contrast to Martin's dismay with the ruling, insurance company supporters lauded the decision as a victory for patients and employers.
"The ruling puts the brakes on efforts by trial lawyers to turn every question about the scope of an individual's coverage into a costly lawsuit," said Karen Ignagni, president and CEO of America's Health Insurance Plans.
Ignagni described the ruling as a victory for consumers and employers who otherwise would have faced higher health care costs without added benefit.
"There is already far too great a reliance on using the courts to resolve disputes in health care, a practice that has had great consequences for the fabric of our health care system," Ignagni said.
To reach writer J. Michael Brodie, e-mail mbrodie@aafp.org.
FP Report is published by the AAFP
News Department.
Copyright © 2004 by American Academy of Family Physicians.