Patients' rights victory: Another step is needed

A U.S. Supreme Court ruling in the Moran HMO appeals case marks a major win, but still falls short of what's needed.

Editorial. July 22, 2002.

The U.S. Supreme Court, in its landmark ruling on Rush Prudential HMO Inc. v. Debra C. Moran, et al., has given patients and physicians a substantial victory. The decision points to the need for one more, even bigger win in Congress.

After the high court's 5-4 ruling, those states that choose to now can guarantee many patients a right to an independent, external review of managed care treatment decisions. More than 40 states already have enacted such laws. But the decision is not a perfect win for patients' rights. The most glaring shortfall: Roughly 56 million patients in employer self-funded health plans are not covered by it.

Nevertheless, it provides new protection to the patient-physician relationship. Those patients covered under the ruling, an estimated 73 million who are enrolled in fully insured plans through work, could have a legal right of appeal if a health plan overrules the course of treatment prescribed by their doctors.

Behind this ruling is a case that was often excruciatingly complex, resting on interpretation of obtuse statutory language, long-ago legislative intent and narrow legal precedents. At its center was a familiar culprit in frustrating the rights of patients: the Employee Retirement Income Security Act of 1974. [...]