N.Y. case raises question of health plan accountability

The plan says it made a coverage decision. Physicians say it was a medical decision and the plan, and its medical director, should bear responsibility.

By Tanya Albert, AMNews staff. March 11, 2002.

Physician groups are asking a federal court to send HMO medical directors a message: If you are going to make decisions about what treatment a patient should get, then you need to face the consequences.

The AMA's Litigation Center and the Medical Society of the State of New York have filed a friend-of-the-court brief in a case against a health plan, Vytra Healthcare, that is now before the 2nd U.S. Circuit Court of Appeals. In it, the physician groups say the New York-based plan should have to answer for going against a physician's recommendation that a patient receive an aggressive cancer treatment.

The health plan argues that its medical director made a policy decision that should be shielded from lawsuits under the federal Employee Retirement Income Security Act of 1974. But physicians say the health plan and its medical director -- who holds a medical degree -- went beyond a coverage decision and ventured into the area of medical decisions.

That, they say, is not protected by ERISA, as evidenced by a previous U.S. Supreme Court ruling.

"If we're successful in this quest, it will bring us back to where we ought to be," said Donald J. Palmisano, MD, AMA secretary-treasurer. "The physician and patient relationship will be one where the physician and patient discuss the treatment options and the patient rejects or accepts the treatment."

The New York lawsuit centers around the treatment of Carmine Cicio, whom physicians diagnosed with myeloma in March 1997. On Jan. 28, 1998, Edward Samuel, MD, decided that Cicio needed high-dose chemotherapy combined with peripheral blood stem-cell transplantation, according to court documents. [...]