Michael Coles has made reform of health maintenance organizations the centerpiece of his campaign to unseat Paul Coverdell, Georgia’s Republican senator. Coles is using ads attacking Coverdell’s opposition to allowing patients to sue their managed-care companies for malpractice. One Coles ad tells the story of a young mother who lost her baby because her HMO refused to cover delivery by Caesarian section. Coverdell has counterattacked by accusing Coles of exploiting a tragedy for political gain. Exposing HMOs to malpractice suits will drive up costs and thus increase the number of uninsured, people as employers drop coverage they can no longer afford, Coverdell argues. He supports a Republican bill to establish an expedited appeals process for patients when HMOs decline to cover treatment. The Coles-Coverdell fight is being played out nationally, as lawmakers in Washington debate proposals for HMO reform and candidates across the country find that HMO reform is one of those hot-button issues to which voters respond. But there is more at stake here than political points. The choice between the differing approaches could fundamentally affect the practice of medicine in this country. Of the two proposals, the Democrats’ comes closer to providing the needed checks and balances on managed-care plans, which cover 75 percent of American workers who have employer-sponsored health insurance. Republicans argue that their plan provides enough protection by allowing patients to appeal to a panel of independent doctors. In fact, they argue, it ensures the final decision will be based on medical needs. Rather than paying patients for their suffering, they say, the GOP plan prevents unnecessary suffering by making sure that appropriate treatment is covered by the HMO. Republicans say HMOs can’t hold down increases in health care costs if they must spend money fighting frivolous lawsuits. The Republicans make good arguments in favor of their appeal process. They provide reason enough to include their plan in HMO reform. But this isn’t necessarily an either/or question. The interests of patients would be well served if they had the right of appeal and the right to sue. If Republicans want to force a choice, the ability to file lawsuits is more important. An appeal process alone will do nothing to change HMOs’ increasing emphasis on cutting costs over covering treatment that a physician has deemed medically necessary. The managed-care companies would have a lot less to lose if their decisions were subject to review only by an appeals panel. If their denial of coverage is upheld, they save money. If they are overruled, they simply pay what they should have paid in the first place. If anything, in cases in which a patient needs an answer for an acute medical problem requiring immediate action, an appeal process -- even an expedited one -- provides an incentive to refuse coverage in order to buy time. By contrast, the threat of compensatory and punitive damage payments would motivate HMOs to make sure that sound medical judgments aren’t run over by the drive for profits. The experience of Texas, which in 1996 became the first state to allow HMOs to be to sued for medical malpractice, is instructive. An evaluation of the impact of the Texas law found that medical costs have not increased significantly, that there has not been an explosion of malpractice lawsuits and that the number of cases of denied coverage has dropped. That shows the reform plan offered by the Democrats is not the poison pill the Republicans say it is. In fact, it will enable more patients to get just what the doctor ordered. |
