I mean, sure – sue the HMO and get a court to say its covered. But we can’t pretend that patients and providers don’t make economic decisions about the care obtained/delivered in much the same way as an HMO does.

Perhaps one problem with the Court’s interpretation of ERISA is that it artificially separates “coverage” decisions from “treatment” decisions. Very few actual decisions are purely one or the other, but the only context in which the Court acknowledges this bit of reality is in situations like the one in Pegram v. Herdrich: a physician who is part of a staff-model HMO.

I think it’s obvious that decisions about coverage and treatment are “mixed” in WAY MORE cases than just this one.

Many of the readers here are docs, and virtually all of us are covered by health plans. This is a question that each of us should be able to answer from our own personal experience.

If you want an insurance plan that will pay for EVERYTHING your doctor thinks you need, buy an indemnity plan that has no pre-certification requirement. What, you can’t find one that you can afford? They have been pretty much priced out of the market for all but the very wealthy. What you get for substantially lower premiums in an HMO is less in return. There are limitations on which providers you can access, and on what they can do. Sometimes, inevitably, the HMO bureaucracy will do something that in retrospect was really boneheaded. In our system, the trial lawyers would put them out of business in a New York minute, and then you’re back to no affordable health care for a lot of non-wealthy people. When HMOs were designed, their marketers knew that they needed statutory protection from lawsuits for them to be viable. That is why the law reads the way it does. It’s analogous to the statutory protection the vaccine makers demanded to continue production. If you want the undeniable good results of mass vaccinations, you have to accept that a few people are going to get hurt and not get the lottery sized compensation that he lawyers have trained us to demand.

You can’t have rich folks’ medicine at poor folks’ prices. We simply can’t afford everything for everybody.

ERISA set down that limit as law. The SC reminds everyone that the law still means what it said when Congress wrote it.

“apparent the SC justices sided with the arguments of the lawyers representing the HMOs”

The Supreme Court, functioning exactly as it should, came down on the side of the law.

Congress created this mess and Congress is going to have to fix it. Three years ago, Congress wimped out on patients’ rights legislation. I’ll bet it wimps out again. After all, a chain of wimps is only as strong as the weakest wimp.

But to blame any of this on the Supreme Court is at best lazy thinking.

One, allowing patients to sue HMOs in state courts would drive up the costs for employers; second, the majesty of the federal law should be upheld over those of state rights, which essentially would reinforce the same language when ERISA was crafted 30 years ago.

I have read the background of the two cases filed in Texas, and the actions contested by the plaintiffs are practices not confined to HMOs, but allowed by companies outside of managed care as well.

Disputes can now be resolved by panels of physicians. If this mechanism does not work to the satisfaction of patients, Congress may have a chance to finally craft a Patients’ Bill of Rights.