This could hardly be seen as a way to lower the healthcare costs of people in this country.
Still, though, it is apparent that something must be done. Healthcare is extremely expensive anymore, and there are more and more people in this country that no longer have health insurance. Because of the lack of insurance that is available to these people, they do not go to the doctor when they really should. As a result, they get sicker until they finally have to go to the emergency room or they end up in the hospital. They certainly cannot pay for these kinds of services any more than they can afford insurance, but hospitalization costs much more than insurance premiums. Since these people cannot pay for the emergency services that they have received, rates for insurance and for procedures must be raised to cover the costs of those that default on medical bills.
From the point-of-view of hospital administration, suing HMOs will likely just bring more paperwork, aggravation, and uncooperative insurance companies that they will then be required to deal with graciously. Also, doctors that sue HMOs will often not be able to work with that HMO anymore, so they will lose patients. This will happen because the HMO will no longer use a particular doctor as a care provider and those that have that HMO will then have to find a new doctor. This happening to a lot of doctors that are affiliated with a hospital could provide disastrous results for the profit margin of that particular hospital. In order to make money, the hospital must then charge more to the patients that it does have, so this will not help work to lower costs in any way.
In Texas, things are moving forward with the idea of suing HMOs. In 1997, it became the first state that allowed a claim against an HMO to go through the court system. This was significant because it will likely lead the way to more of these cases in Texas and also across the country. In one of the cases that was presented in Texas one of the main medical directors for a healthcare organization was forced to be held accountable for the decisions that he made from a medical standpoint (Reece, 2000).
This was significant because it will require others in this field to do the same. This is important for medical directors of HMOs, but it is also important for hospital administrators, as the need for discipline of those acting as medical doctors is clearly necessary. This is not as large of a concern as it relates to lawsuits as is the money that could be lost by hospitals that will lose patients. Since the time that Texas created their law, however, eight other states have also passed laws allowing for HMOs to be sued. The Supreme Court, however, has tried to remain removed from the issue as much as possible. The Court did say, however, that the ERISA guidelines could not be used to sue HMOs. This is not the same thing as saying that HMOs cannot be sued at all (Reece, 2000).
One of the main problems that many have with the HMOs is that they are not required to be nearly as responsible as doctors and others that are involved with the healthcare system. This lack of accountability has much to do with why there is a movement in this country to make HMOs available for litigation. Hospital administrators, however, see that allowing for this kind of litigation would provide many more people with an opportunity to sue people and get wealthy for things that really should not be sued over. There are some reasons that lawsuits should certainly be filed, especially in cases of obvious negligence, but Americans today file an amazingly large amount of lawsuits, and many are truly unnecessary. These kinds of lawsuits are already a problem for the medical community and they will only become more problematic if suing HMOs becomes big business (Alter, 2001).
The main reason that HMOs have not been sued is because of the ERISA law, which protects employee benefit plans. Because it protects these kinds of plans, it also protects HMOs. This is changing, however, as has been mentioned. Another issue about whether HMOs should be sued has to do with whether patients are getting the care that they really need. A case in point is one young woman, the mother or two, who thought that she had appendicitis. She went to her doctor, who said it was a urinary tract infection, gave her some medicine, and sent her back home (Decarlo, 2000).
The lab tests showed that she did not have a UTI after all, and the doctor found a mass in her abdomen, but decided that it was not an emergency. Finally, the scan that she got, eight days after the second doctor visit, showed that her appendix had burst. This caused internal damage and spread infection throughout her abdomen. She almost died. There are many cases like this, and the argument about this is that doctors that work with HMOs and are trying to save money often do not check patients thoroughly or give them the tests and procedures that they might need. This is largely because many of these doctors get paid a specific amount, regardless of how much time they spend with their patients or how many tests that they order. This is the main concern that many have when it comes to whether HMOs are doing everything that they can to help patients get good healthcare at an affordable cost, which is what they were really designed for (Decarlo, 2000).
Healthcare administrators are concerned about this potential for new lawsuits because of what might happen to the costs of healthcare. It would appear, though, that despite the ability to sue HMOs in several states, there have only been a few lawsuits. Those that were worried about getting flooded with lawsuits have not seen this happen, and many lawyers are actually disappointed because they thought that they could make a great deal of money off of many of these high-dollar lawsuits. That does not mean that there will never be a flood of HMO lawsuits, but it has not happened yet (Kilcullen, 1996).
People that work in healthcare administration are breathing a collective sigh of relief that there have not been more lawsuits. The idea of excessive lawsuits has been upsetting to many. Now that it would appear that this will not be an immediate concern, people are taking another look at the entire issue and what it will mean for patients, doctors, HMOs, and hospital administration. More lawsuits coming to light and the Supreme Court potentially getting involved in whether HMOs can be sued and on what grounds that this might be possible in the future will undoubtedly change the scope of things (Kilcullen, 1996).
The limitations that HMOs place on care, however, greatly affect those that need the care the most, and this is realized by hospital administration. Unfortunately, there is not always anything that the hospital administration can do to help these people. The bottom line is that they are around to make money, even though the also try to help people to live longer and enjoy their lives. This interest in money makes them vulnerable to the things that HMOs want to do, because they have to be able to make a profit (Perry, 2001).
The more the rates for things like tests and surgical procedures rise, the more that individuals need insurance and HMOs to pay for these things. If HMOs are forced to raise their rates because they are being sued, more people will be unable to afford the insurance that they need. They will opt for emergency services only when absolutely necessary, and because of their inability to pay for it, healthcare costs and insurance premiums will go up yet again. This has become a vicious circle, and one that hospital administration is watching very carefully, in the hopes that they will find some way to break this cycle. Most of them do not believe that suing HMOs will help this at all (Perry, 2001).
There are others, though, that still maintain that HMO premiums have not gone up even though there have been lawsuits. This may be factual. However, there have been so few lawsuits to this point that it is really impossible for anyone, including healthcare administrators, to determine whether this will really significantly affect the amount that people have to pay for their healthcare (Perry, 2001). Since there are both pros and cons to being able to sue HMOs, it is clearly something that has to be studied very carefully.
Hospital administration, patients and their advocates, doctors, and many others must spend time…