新作坊 Humanity Innovation and Social Practice

Managed Health Care Organizations

摘要：

"Managed health care," or "managed care," is a comprehensive term that includes all types of combined health finance and delivery systems. This chapter of Personal Injury: Actions, Defenses, Damages considers the liability of a managed health care organization (MCO) to its patients/members for medical malpractice and other causes of action. It covers both actions against MCOs and defenses to those actions. Theories of recovery fall into two general categories: (1) quality of care cases, in which the patient/member claims that the services actually provided under the plan constituted negligence of the MCO or that the MCO is vicariously liable for the malpractice committed by an MCO physician; and (2) denial of benefits cases, in which the patient/member argues that needed care was not provided, often because of an adverse utilization review, in violation of the MCO's duties under the contract of care between it and the patient/member. Other claims asserted against MCOs include interference with the physician-patient relationship and breach of fiduciary duty. The most important defense to claims by patients/members against an MCO is statutory preemption. Generally, cases based on the denial of benefits relate to the operation or administration of the MCO and, therefore, are preempted by the federal Employee Retirement Income Security Act of 1974 (ERISA). However, suits alleging inferior quality of care are usually not preempted, and these cases hinge on state law principles, such as those of medical malpractice, which are laws of general application and are not intended to address the relationships between ERISA plan participants. State statutes have endeavored to provide some objective expression of the rights of MCO patients/members, and to curb some of the worst abuses of utilization review, such as small drug formularies. However, these statutes all relate to the operation of the plans and have been preempted. This chapter also addresses arbitration of claims against MCOs in the light of trends favoring alternative dispute resolution and includes a discussion of litigation issues.