The Health Care Blog reminds that oral argument occurred yesterday in the U.S. Supreme Court in an appeal of this Fifth Circuit decision, which involves tort claims against HMO’s under the Texas health care liability statute and the HMOs’ contention that claims under the state statute are preempted by the federal ERISA statute. The Fifth Circuit previously rejected the HMOs’ attempt to use ERISA preemption to remove the tort cases to federal court and upheld the plaintiffs’ right to litigate their claims in Texas state courts, which are rarely as corporate-defendant friendly as federal courts. The Supreme Court’s decision in this case will address a festering issue in ERISA law — that is, whether an HMO’s medical-necessity determinations are really benefits determinations that are completely preempted by ERISA.
As you might expect, the battered health care finance industry is closely eyeing the outcome of this case. The applicable ERISA provision provides a narrow basis for recovery against plans that withhold a requested level of care and a conservative measure of damages for successful plaintiffs. On the other hand, as is Texas’ tradition, Texas tort law provides injured plaintiffs with a more liberal basis for recovery and thus, exposes health plans to far greater economic risk.
So long as HMOs and other managed care units are forced to make mixed coverage and treatment decisions against a backdrop of potential tort liability, opponents of managed care believe that the managed care units would be far less willing to risk limiting or denying care that physicians and patients request. On the other hand, HMO’s and managed-care plans view an adverse result in the case as a threat to the financial security of employee benefit plans that extend health coverage to millions of workers and retirees.
Tom Mayo, the health care lawyer who is the author of the Health Care Blog, seems to think that the Supreme Court is leaning in favor of the managed care plans and federal preemption. However, the Supremes are notoriously difficult to read in cases such as this, so follow this one closely.