Press "Enter" to skip to content

Who Wins Witherisa

.. a high-risk pregnancy because of her history with pregnancy-related problems. Taking this into careful consideration, her doctors recommended hospitalization so that the fetus could be monitored as the due date approached, and another obstetrician (who was used for a second opinion) concurred (Pollack). Despite her doctors request, United Healthcare insistently denied the hospitalization, but appointed an in-home nurse to attend Mrs. Corcoran ten hours a day.

While the nurse was off duty, the fetus developed complications and died. Mrs. Corcoran and her husband brought their litigation to court, alleging that the MCOs decision not to provide her with the hospitalization caused the death of their unborn child. Despite the obvious injustice, the courts ruefully ruled in favor of the MCO because of the ERISA preemption clause. Sadly, but true enough, the haplessness of this situation can be best put in the words of Bob Herbert of the New York Times, Insurance companies are not in the business of curing people, they are in the business of making money.

Pssst… we can write an original essay just for you.
Any subject. Any type of essay.
We’ll even meet a 3-hour deadline.


Get your price

They will use any excuse to deny payment of what they perceive as more expensive therapy (qtd. in Zelman and Berenson 106). Under ERISA, patients are entitled to equitable relief. This means that a patient can recover the value of the denied service, which sometimes comes far too late. However, ERISA restricts patients from obtaining monetary damages or compensation to make him or her whole from the benefit denial, even in an event of loss of life because of the health plans improper denial (Pollack).

The Corcoran family only received in compensation, the value of the denied hospitalization, an insignificant amount compared to the life that was lost. The Patients Bill of Rights, supported by the American Medical Association and the American Nurses Association to name a few, would ensure an end to MCOs wrongful conduct. Should Congress enact this bill, the Patients Bill of Rights would provide patients an independent authority where they can appeal their managed care plans decisions. Patients would also have the right to hold health plans accountable when things go wrong. Another important aspect of the bill is that it would allow patients to get emergency services when the patient thinks he or she needs them.

Had this bill been approved in previous legislative reforms, Troy Benoit would still be walking today. In Benoit v. WW. Grainger, Inc. et al., No.

98-1315, 1998 U.S. Dist. LEXIS 16988, 7 (E.D. La. Oct.

21, 1998), Mr. Benoits health insurer, Aetna, refused to provide the emergency services he needed. After sustaining serious neck and spinal injuries from a motorcycle accident, hospital physicians urgently recommended that he have surgery immediately. Aetna formally refused to fund the procedure, but eventually certified it. Despite the reversed decision, Mr. Benoit was left paralyzed with little or no chances of ever walking again (Amer.

Psych. Assoc.). It is evident that the tax code unintentionally limits the choice of health plans that employees can choose from, sometimes being limited to only one choice. Employees are wrongfully compelled to join a health plan that is not in their best of interests. Regulations imposed on physicians also add to inadequate health care. The failure of the intended role of ERISA, to protect employees, predominantly adds to the inefficiency of the managed care system.

The working American, thus, is truly a victim of a non-ending cycle of negligence and irrationality embedded in the lawmaking by Congress. Yet opponents in Congress and the managed care industry, especially self-insured employers, have reasons to believe that expanded liability will force insurers and employers to pay for unnecessary health care, encouraging employers to drop health coverage. Also, the Patients Bill of Rights will increase health plan costs, which would ultimately increase the number of the countrys uninsured. The managed care industry fears that the Patients Bill of Rights would have a reverse effect. The opponents of legislative reform argue that expanded liability on ERISA-regulate MCOs (mainly the employer-based system) would force insurers and employers to practice defensive utilization reviewpaying for unnecessary or inappropriate health care to reduce their risk of even more costly litigation (Arg. Against Liability).

Patients would have the incentive of taking advantage of health care services causing an unbalance in the health care budget. If managed care legislation passes, it would further more encourage employers to drop health coverage. If employers were to be discouraged from providing health insurance, this would force insurance companies to downsize their networks and eventually consumers would have substantially less choice among available types of coverage (Arg. Against Liability). Another point that opponents of the Patients Bill of Rights want to clarify, is the effect that managed care reform will have on the costs of health insurance. Because the health system is so competitive, insurers cannot afford to absorb the increased cost of expanded liability (Arg.

Against Liability). These costs would be passed on to employers, who also cannot afford to absorb the costs. Unfortunately, these costs are eventually passed on to employees, either directly or indirectly lowering their pay or decreasing the amount of benefits they receive (Hoffman 17). Moreover, expanded liability could escalate the costs of health care. Increased costs of health plan coverage would have a chilling effect in increasing the number of uninsured Americans. This negative aspect of managed care reform is supported by the general counsel of the Self Insurance Institute of America, Brian Davenport, who also practices law in Franklin, Indiana: If you substantially increase the cost of providing the benefits, I think theres a strong possibility that you will substantially increase the number of people without benefits (Hoffman 17).

The supporters of the managed care industry and the employer-based health care system have brought into perspective, rational arguments. Despite their contrasting viewpoints, they fail to realize that employers are not the ones making the medical decisions, managed care plans are. Managed care reform protects employers from liability when they are not involved in the medical decision that results in harm. The principle that we should be held accountable for our own actions is universally accepted. The bottom line is that managed care plans should be held accountable, just as everyone else is.

Congress can improve ERISA by explicitly removing the preemption clause that currently limits states abilities to establish accountability for wrongful denials of MCOs to their patients. If ratified, the Patients Bill of Rights would amend the loophole in ERISA. Congress should do its part to protect the welfare of those Americans that are affected by ERISA-regulated MCOs. Three of the top managed care organizations in the industry, including Kaiser Permanente, are calling for legally enforced standards. Clearly, when respected leaders of an industry are calling for standards to be placed upon themselves, it is a sure sign that Congress should act (Managed Care Reform: Fact vs. Fiction).

Works Cited Clinton, Bill. The Presidents Radio Address. Weekly Compilation of Presidential Documents. 10 August 1998: 1556. ERISA Managed Care Organizations Should Be Held Accountable for Decisions that Harm Patients. 1 February 1998. *http://www.apa.org/practice/erisa.html* (21 April 1999).

Fox, Peter D., et al., eds. Determinents of HMO Success. Office of Health Maintenance Organizations. January 1998: 56. Hoffman, Ronald F.

and Mark O. Hiepler. An Easy Out for Managed Care. The Washington Post. 4 April 1998: A19. Managed Care Reform Legislation: Fact vs.

Fiction. 1 January 1999. *http://www.patientadvocacy.org/main/managed care/mcrl fvf.html* (21 April 1999). Managed Care: What Consumers Need to Know. 3 August 1998. *http:www.aarp.org/monthly/managedcare/home.html* (21 April 1999). Pollack, Ron. Current Problems with the Federal Employment Retirement Income Security Act of 1974.

14 May 1998. *http://www.familiesusa.org/erisa2.htm* (21 April 1999). Zelman, Walter A. and Robert A. Berenson. The Managed Care Blues and How to Cure Them. Washington D.C.: Georgetown Press, 1998. Do You Yahoo!? Talk to your friends online with Yahoo! Messenger.

Bibliography Works Cited Clinton, Bill. The President’s Radio Address. Weekly Compilation of Presidential Documents. 10 August 1998: 1556. ERISA Managed Care Organizations Should Be Held Accountable for Decisions that Harm Patients. 1 February 1998. (21 April 1999).

Fox, Peter D., et al., eds. Determinents of HMO Success. Office of Health Maintenance Organizations. January 1998: 56. Hoffman, Ronald F.

and Mark O. Hiepler. An Easy Out for Managed Care. The Washington Post. 4 April 1998: A19.Managed Care Reform Legislation: Fact vs.

Fiction. 1 January 1999. http://www.patientadvocacy.org/main/managed care/mcrl fvf.html (21 April 1999). Managed Care: What Consumers Need to Know. 3 August 1998. (21 April 1999).

Pollack, Ron. Current Problems with the Federal Employment Retirement Income Security Act of 1974. 14 May1998. (21 April 1999). Zelman, Walter A.

and Robert A. Berenson. The Managed Care Blues and How to Cure Them. Washington D.C.: Georgetown Press, 1998. Social Issues.

x

Hi!
I'm Lily

Would you like to get a custom essay? How about receiving a customized one?

Check it out