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INSURANCE LITIGATION |
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HMO LIABILITY: |
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BACKGROUND:¹ The acronym "HMO" stands for "health maintenance organization." It has become the commonly accepted shorthand reference for health care delivery through what is also known as a "managed care organization" or "MCO." The legal origin of HMO can be found in the federal Health Maintenance Organizations Act (42 U.S.C. 300e et seq.) There is no specific entity known as an HMO or MCO under California law; rather, managed care organizations are organized under the Knox-Keene Act ( Health & Safety Code §§1340 et seq.), and are known as "health care service plans" or HCSP's. Health & Safety Code §1345(f) defines "health care service plan" as "any person who undertakes to arrange for the provision of health care services to subscribers or enrollees, or to pay for or reimburse any part of the cost for those services, in return for a prepaid or periodic charge paid by or on behalf of the subscribers or enrollees." (Note: the term "person" includes corporations and other business forms - C.C.P. §17; Ins. Code §19). The first HMO was originated by the Kaiser Permanente organization in the 1930's, initially for employees of Kaiser entities in Northern California. It was not until the 1970's that HMO's really began to proliferate resulting in fundamental and dramatic changes in the way health care is insured and provided in California and throughout the United States. Under the traditional system of health care delivery people were insured under indemnity insurance policies which covered fee-for-service medical care. The choice of health care provider was made by the insured and there was a one-to-one doctor-patient relationship. Under new HMO systems there is no indemnity or reimbursement promise made to the plan member, but rather there is a promise to provide the health care itself through arrangements made between the risk-assuming organization and health care providers, such as doctors and hospitals. Managed care systems involve pre-agreed rates of reimbursement or compensation, limited care and choice options, and generally aggressive use of utilization review of services provided. As a result of these widespread, fundamental changes, there has been disruption and instability in the health care delivery system, and a shift in values from individualized, voluntary choice to corporate directed involuntary health care decision making. In the process, there has been a general disenfranchisement of health care providers in terms of their power to make fihnal care and treatment decisions, and an increase in the potential for conflicts of interest between and among the participants in the system, including the health plans, doctors and hospitals. Coinciding with these dramatic changes has been the development of significant friction or tension between the business objectives of the new HMO models, including for-profit models on the one hand, and the traditional legal standards applied to the insurer-insured and medical care provider-patient relationships delineated by the legal duties and obligations imposed by law, on the other hand. Much of the transition from traditional indemnity insurance to managed care has been driven by the microeconomics of health care delivery. According to statistics released in 1997, while the consumer price index was increasing at a rate of at or below 3% during 1994 and 1995, inflation in the medical care sector was increasing at closer to 5% overall. Within the specific sub-sectors of health care delivery the cost of paying premiums was increasing on private indemnity insurance in the range of 10-15%, in PPO's 9-10%, and in POS plans 5-7%, while in HMO's only 0-3%. It appears, from the perspective of the author, based on examination of HMO contract changes, that much of the premium cost savings in the HMO sector has been was accomplished by reductions in coverage, services and benefit amount limits, in addition to the effects of price competition and aggressive cost containment (utilization review and claims handling). The typical organization of an HMO involves a risk-assuming organization, typically a corporation, which may be either not-for-profit or for-profit, and which develops plans (as opposed to insurance policies) promising to arrange and provide health care or other health benefits and services as specified in plan documents for a specified period of time. This is substantially different than the arrangements under traditional health insurance policies in a number of particulars. First, health insurance policies did not promise to provide care or services, but rather promised to reimburse insureds for the payment obligations they incurred in obtaining health care of their choice, subject to certain policy restrictions, such as the requirement that the care be medically necessary or that major procedures or hospitalizations be pre-authorized. Second, traditional health insurance policies promise reimbursement for reasonably necessary medical care related to or arising from sickness or accident that occurred while the policy was in force (while the insured was covered); HMO's, on the other hand, promise to provide health care during fixed periods of time, typically one year, and subject to change annually or on thirty days' notice. Third, as a corollary to the second difference, under traditional insurance the right to the reimbursement levels provided in the insurance policies generally vested as of the time the illness or injury occurred, while under HMO plans there is typically no right to have the same care or benefit levels from one period of coverage to the next if there is a reduction or elimination of the benefit. The HMO or health plan, having made the promise to provide care or benefits, then contracts with health care providers or providers of health-related services to actually provide the care, services or benefits. These contracts can be with providers such as hospitals and medical groups, as well as drug and other companies. In addition, there are often supplementary contracts which are known as "carve outs" for such things as dental care, vision care, psychological counseling, and the like. These contracts generally provide for what are called "capitated rates" or "capitation." Under this system the health care providers agree to accept a flat fee for each patient enrolled and in turn promise to provide the care. Under capitation the health care providers are taking a risk that the capitated rates will cover their costs of providing the care, plus a profit. There may be a number of variations that include such things as bonus or penalty pools, which are balanced at the end of agreed accounting periods, and there may also be both negative and positive incentives either within the pool or by other agreement. Under a capitation system the hospital group or medical groups hire, or they internally provide their own, utilization review or case management in order to monitor the amount of care and its cost. In health service plans that do not have capitation, there may be direct contracts between the health plan and the care providers that are subject to different arrangements whereby the health care providers agree to be part of a network of providers for the health plan in exchange for payment of "allowable amounts" for various types of care and service, all on a negotiated basis. Typically, in contractual arrangements between health plans and medical groups or IPA's (independent practice associations) it is the group or association that agrees to be the provider of care or services on behalf of the health plan, and increasingly the individual physicians or other health care providers are employees of the groups or associations. Managed care organizations generally require that health care providers maintain their own medical malpractice insurance. In addition, HMO's have often contractually imposed upon medical care providers "gag clauses" by which the medical care providers agree, depending on the language of the particular clause, not to discuss with patients the treatment options that have been eliminated or reduced by the HMO, the payment or reimbursement policies of the HMO, the financial arrangements between the HMO and the care providers, and criticisms in general about the way the care is managed or the HMO is run. In between traditional indemnity fee-for-service insurance and a full HMO approach are intermediary arrangements such as preferred provider organizations (PPO's) or point of service organizations (POS) under which the plan member or patient may choose and select from a pre-approved panel of health care providers with a number of different options. For instance, a PPO arrangement may provide that if one selects from a preferred provider list the insured gets favorable treatment on co-pays and deductibles, and if they select from a non-preferred list there will be higher co-pays and deductibles; if they choose to go out of plan or network they will incur even higher costs for the care or no coverage at all. Managed care arrangements, involving risk pooling, are generally thought to have the following direct effects on the provision of health care--decreased usage and access, (and therefore decreased medical visits), standardization of medical procedures and decision making, decreased hospitalizations and length of hospitalizations, and decreased use of specialists, especially as a result of the requirement that a patient cannot see a specialist without first seeing a primary care physician (PCP) who acts as a "gatekeeper" to provide non-specialized care at a lower rate. This latter function is controversial, especially in circumstances where the "gatekeeper" primary care physician is part of a capitated system and their ultimate compensation and profit may be affected by the gatekeeping decisions they make. To compound the problem, it is generally thought that profits have proved to be illusive for doctors and hospitals under HMO structures, with doctors' incomes decreasing and medical groups and hospitals going in the red. An emerging trend, in fact, is the exodus of doctors from large groups and IPA's who set up independent practices that refuse to accept HMO patients. In a recent New England Journal of Medical article, reporting on a University of California study, it was asserted that doctors under capitation arrangements who manage their own care decisions reduce hospitalizations and office visits more than managed care doctor/ employees in HMO's. The reduction of hospitalizations reported was around 40%, and it was also found that the phenomenon was more typical on the West coast than on the East coast; quality of care was not evaluated. A 1997 survey of consumer experiences in managed care, the Health Rights Hotline, which is sponsored by the Kaiser Family Foundation, Sierra Health Foundation and the California Wellness Foundation, found that 20% of managed care consumers in the Sacramento area had reported difficulty with their health plan, and 39% of those (or 11% of the survey) reported it as a major problem. Forty-two percent of the problems related to delay or denial of care or payment, 32% related to limited access to physicians and 11% involved concerns about quality of care relating to inappropriate or inadequate treatment, facilities, diagnoses or obtaining test results. According to a recent poll reported in the New York Times, the United States has the highest dissatisfaction with medical care among all western developed countries, and also has the lowest confidence in government as a vehicle to address health care problems. However, in terms of demographics, there seems little doubt that the trend from indemnity fee-for-service to managed care is ongoing and increasing. As of 1997, 110 million Americans were under one form or another of managed care, and it was estimated that number was increasing by a rate of 14,000 per day. In a study done in 1996, it was found that over 13 million people were in HMO's in California, and this growth was continuing. In Sacramento County it was found that 90% of the population was insured or covered for health care, and of that number 45% were in HMO's, 24% were under indemnity insurance, 9% were under MediCare, 6% under Medicaid (MediCal), 6% under PPO's, and 2% under CHAMPAS (federal military retired and dependents). BASES OF LIABILITY: ² Broadly speaking, liability against HMO's can be divided into two main categories, as follows: (1) Quantum of care issues, and (2) Quality of care issues. See discussion in Priboda v. Schpritz, 914 F.Supp. 113 (D. Md. 1996). Under quantum of care are the following potential bases of liability:
Under quality of care the bases of liability are usually medical malpractice and related claims. Overarching claims or bases of liability that, depending on the facts and circumstance of a particular case, may apply either to quantum of care or to quality of care issues, are the following:
In addition, because the promise made under managed care contracts is to actually provide care or services, as opposed to reimbursement to the member after the fact of care, managed care cases involving denial or delay of treatment may, in extraordinary circumstances, lend themselves to equitable remedies, and especially to injunctive relief in order to prevent irreparable harm that cannot be remedied by a monetary award; in other words, circumstances involving imminent threat of injury or death in the absence of medically necessary care. TYPICAL COVERAGE CONTROVERSIES: Coverage or service authorization (quantum of care) disputes involving health care service plans that frequently arise are as follows:
Not all of these circumstances give rise to a valid claim or potential liability. Whether a case exists and should be pursued depends on evaluation of the particular plan language, the relevant facts and applicable law, some of which was highlighted above. STATUTORY CONSIDERATIONS: Most of the California statutes regulating health care service plans are found in the Knox-Keene Act, Health & Safety Code §§1340 et seq., including the following: H & S §1348.6 prohibits contracts between health plans and health care providers which contain any incentive plan including payments to directly induce denial, reduction, limitation or delay in appropriate medical services; however, this section expressly authorizes general capitation payments or shared-risk arrangements not tied to specific medical decisions. H & S §1358 et seq. provide detailed regulations concerning Medicare supplemental contracts. H & S §1363.1(a) provides requirements of disclosure for binding arbitration clauses, including a provision that requires a health care service plan to indicate whether medical malpractice claims are subject to arbitration; presumably, therefore, this is an acknowledgment that health care service plans can be sued for medical malpractice. However, see H & S §1371.25, below, which limits the vicarious liability of health care service plans. H & S §1363.5 requires that health plans develop and report to the Commissioner of Corporations their criteria established for authorizing or denying benefits; this can provide fertile ground for discovery in a health plan case. H & S §1367 spells out the minimum requirements for legally establishing a health care service plan in California. H & S §1368 et seq. provides the requirements for grievance, appeals and external independent review processes; these are generally mandatory in plans and constitute administrative remedies which must be exhausted before suit can be filed. H & S §1370 requires that every health plan establish procedures in accordance with department regulations for continuously reviewing the quality of care, performance of medical personnel, utilization of services and facilities, and costs; immunity and privilege is established by the statute for any quality of care review, utilization review or peer review activity, but the statute expressly provides that the provision does not immunize a health care service plan in any circumstance where a cause of action would arise notwithstanding the provision. H & S §1371 specifies the duties and obligations of health care service plans with respect to the reimbursement of claims, including the timing of claims payment decisions. H & S §1371.25 is a centrally important statute relating to potential bases of liability for health care service plans, and states as follows: A plan, any entity contracting with a plan, and providers are each responsible for their own acts or omissions, and are not liable for the acts or omissions of, or the costs of defending, others. Any provision to the contrary in a contract with providers is void and unenforceable. Nothing in this section shall preclude a finding of liability on the part of a plan, any entity contracting with a plan, or a provider, based on doctrines of equitable indemnity, comparative negligence, contribution, or other statutory or common law bases for liability. H & S §1373 et seq. spell out required and prohibited provisions in health care service plans. In addition to the foregoing, California Civil Code §3296(a) requires that judgments against an insurer or a health care service plan for punitive damages must be reported to the Commissioner of Insurance (insurers) or Commissioner of Corporations (HCSP's); from this, one may conclude that punitive damages are not prohibited. As a result of legislative enactment of Civil Code §3428, a new statute-based health service plan or managed care negligence cause of action may become available effective January 1, 2001. Whether and to what extent this cause of action will become available may depend upon the ongoing evolution in case law involving preemption of state law-based remedies by federal statutes, especially the Employee Income Retirement Security Act of 1974 (ERISA) and/or potential enactment of a federal "Patient Bill of Rights" law. See further discussion below. Civil Code §3428 provides, for services rendered on or after January 1, 2001, that a health care service plan or managed care entity shall have a duty of ordinary care to arrange for the provision of medically necessary health care service to its subscribers and enrollees, and shall be liable for harm legally caused by failure to exercise that ordinary care when both of the following apply:
Substantial harm is essentially defined as loss of life, loss or significant impairment of limb or bodily function, significant disfigurement, severe and chronic physical pain, or significant financial loss. The statute prohibits health plans from seeking indemnity against the medical providers, and the statute expressly prohibits liability against employers. Otherwise, it does not abrogate or limit any other theory of liability otherwise available. The damages recoverable are those generally available in tort under Civil Code §3333 (all detriment legally caused, whether anticipated or not). For purposes of preemption analysis, Civil Code §3428 was accompanied by legislative findings and declaration of intent that health care service plans and all other managed care entities regulated under the California Health & Safety Code are engaged in the business of insurance as that term is used under the McCarran-Ferguson Act (15 U.S.C. §1011 and following), even though California has chosen to regulate health service plans through a separate department, (prior to 2000 through the Department of Corporations), and outside the jurisdiction of the Department of Insurance and the Insurance Code. Nothing in the statute, however, relieves any health plan member from the responsibility of exhausting administrative remedies or from the requirements of any valid mandatory binding arbitration provisions. Approximately 65-70% of health insurance and HMO plans are governed by ERISA, including all employer paid or sponsored plans (29 U.S.C. §1002), except those covering government or church-affiliated employees (29 U.S.C. §1003) and those subject to the U. S. Department of Labor "safe harbor" regulations (29 C.F.R. §2510.3-1j). If under ERISA, plan participants and beneficiaries are limited, in terms of remedies, to plan benefits, injunction or other equitable relief, and attorney fees and costs (discretionary). 29 U.S.C. §§1132(a)(1), (a)(3), and (g), respectively. For a number of years now Congress has been wrangling over "reform" of health care interfaced with "tort reform." The vehicle for this ongoing debate, primarily a conflict between Republicans and Democrats, has been what is generically called "The Patient Bill of Rights." The Patient Bill of Rights has taken many different forms with many different authors and combinations of co-authors in Congress. As of this writing, in September 2000, four major proponents who are generally considered moderates - Representatives Charlie Norwood (R-Ga.), John Dingell (D-Mi.), Greg Ganske (R-Ia.) and Sen. Ted Kennedy (D-Ma.) have proposed a new compromise bill that would apply to all private health insurance and health service plans, presently covering about 160 million Americans. As reported, this bill would protect states' rights to regulate health insurance and allow patients to file suit against HMO's in state court only if a health plan denied a claim because "a service was not medically necessary...or experimental." Patients reportedly would have to sue in federal court to challenge an HMO's administrative decision to deny benefits which are not related to medical judgments. The bill is strongly supported by the American Medical Association. This compromised bill runs counter to other versions that are co-sponsored by Democratic and Republican leadership, which also are in conflict. Whether any bill will pass and be signed by President Clinton is unknown, but from the standpoint of concern states' rights and for the viability of state law-based rights and remedies no Congressional action might be preferred in the present climate lest the bill title - Patient Bill of Rights -- be just a cruel misnomer. Other statutory bases of liability that presently exist include the Racketeer Influenced Corrupt Practices Act (RICO) and California's Business & Professions Code §17200 et seq. (Unfair Competition Act). See below. COMMON LAW CONSIDERATIONS: Plan interpretation: Benyon v. Garden Grove Medical Group (1980) 100 Cal.App.3d 698, 704 (plan documents are adhesion-type contracts, and ambiguities should be interpreted in favor of plan members). Sarchett v. Blue Shield of California (1987) 43 Cal.3d 1, 13, fn. 14 (same; doubts respecting coverage, including reasonableness of treatment, must be resolved in favor of plan member). Mongeluzo v. Baxter Travenol, 46 F.3d 938 (9th Cir. 1995) (same basic plan interpretation rules apply in ERISA actions as a matter of federal common law). Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 386 (9th Cir. 1994) (the reasonable expectations doctrine applies to ERISA plans). Barnes v. Independent Auto. Dealers of Cal., 64 F.3d 1389, 1393 (9th Cir. 1995) (ambiguities in plan must be resolved against drafter and in favor of member). Vesting of benefit levels: Fraker v. Century Life Insurance Company (1993) 19 Cal.App.4th 276 (vesting rules applicable to indemnity insurance policies, as recognized in Fields v. Blue Shield of California (1985) 163 Cal.App.3d 570, 585-86, do not apply to health care service plans which provide for medical services during specified time periods). Williams v. California Physicians Service dba Blue Shield of California (1999) 72 Cal.App.4th 722 (same). Babikian v. The Paul Revere Life Insurance Company, 63 F.3d 837 (9th Cir. 1995) (California's vesting rules preempted by ERISA and therefore not applicable to ERISA plans). Utilization review decisions: Wilson v. Blue Cross of California, (1990) 222 Cal.App.3d 660 (no immunity attaches to utilization review decisions, and a medical care provider decision concerning the care provided does not supersede plan responsibility). Wickline v. State of California (1986) 192 Cal.App.3d 1630 (medical care providers have responsibility to determine whether hospitalization is required, and may be liable even if plan utilization review did not authorize extension of hospital stay). Corporate negligence, non-delegable duty, fiduciary duty: Wickline v. State of California, supra (inappropriate decisions resulting from defects in the design or implementation of costs containment mechanisms, such as when a patient's appeal is arbitrarily ignored or unreasonably disregarded or overridden, may give rise to direct liability against a plan). See Thompson v. Nason Hospital, 591 A.2d 703 (Pa. 1991) (corporate negligence and non-delegable duty discussed). Moore v. Regents, University of California, (1990) 51 Cal.3d 120 (disclosure of personal interests and potential conflict of interests by providers discussed). Medical necessity: Hughes v. Blue Cross of No. Cal., (1989) 215 Cal.App.3d 832 (good faith requires construction of the medical necessity requirement consistent with community standards and a thorough review of medical records, the acquisition of which is the responsibility of the plan. Health plan bad faith (tort liability): Sarchett v. Blue Shield of California, supra, at fn. 1 (California Supreme Court holds that for purposes of determining liability for breach of implied covenant of good faith and fair dealing there is no legal distinction between a health insurer and a health care service plan). Brandt v. Superior Court (1985) 37 Cal.3d 813 (claimant entitled to recover, as damages, the amount of attorney fees and costs reasonably incurred to recover contract benefits). ERISA preemption: Pilot Life Insurance Company v. Dedeaux, 481 U.S. 41(1987) (under ERISA "relate to" clause quantum of care claims preempted; ERISA civil enforcement provisions provide separate preemption ground based on exclusive remedy doctrine). New York State Conference of Blue Cross and Blue Shield Plans v. Travelers Insurance Company, 514 U. S. 645, 115 S.Ct. 1671 (1995) (indirect economic influence on and administrative cost to plan does not justify ERISA preemption). FMC Corp v. Holliday, 498 U.S. 52 111 S.Ct. 403 (1990) (ERISA treats self-funded and insured plans differently; together with ERISA savings clause, it may be concluded that ERISA reserves to the states the right to directly regulate insurers as well as the substantive terms of insurance contracts); see also International Resources, Inc. v. New York Life Ins. Co., 950 F.2d 294, 301 (6th Cir. 1992). UNUM Life Ins. Co. of America v. Ward (1999) 526 U.S.358, 119 S.Ct. 1380 (Pilot Life's "relate to" ERISA preemption analysis has given way to traditional federal preemption doctrine analysis and no longer applies; California's common law notice prejudice rule deemed a law regulating business of insurance under McCarran-Ferguson Act and therefore saved from preemption under ERISA savings clause. Washington Physicians' Service Ass'n. V. Gregoire, 147 F.3d 1039 (9th Cir. 1998) (Washington state mandate that HMO's cover alternative medical treatments saved from ERISA preemption) under insurance savings clause. See also Kentucky Assn. Of Health Plans, Inc. v. Nichols, ___F.3d___, 2000 WL 1264604 (6th Cir. 2000) (any willing provider state statute). Pegram v. Herdich, ___ U.S. ___, 120 S. Ct. 2143 (2000) (mixed eligibility and treatment decisions made by HMO, acting through its physicians, were not fiduciary acts within ERISA; capitation, generally, and its inherent conflicts not basis for legal action). Pappas v. Asbel (and Pennsylvania Hosp. Ins. Co. v. U. S. Healthcare) 724 A.2d 889 (Pa. 1998) (Pennsylvania Supreme Court initially held that third party cross-complaint by medical provider against HMO alleging delay in benefit decision contributed to plaintiff's alleged injury was not preempted by ERISA; but cert. granted and judgment vacated, case remanded (120 S. Ct. 2686) to Pennsylvania Supreme Court for reconsideration in light of Pegram v. Herdich, supra). Quality of care v. quantity of care preemption decisions: See Priboda v. Schpritz, supra, (D. Md. 1996) (terminology and distinction between quality of care and quantity of care decisions as bases for claims discussed). Dukes v. U. S. Health Care, Inc. 57 F.3d 350 (3rd Cir. 1995) (quality of care claims, such as medical malpractice, not preempted by ERISA). However, see also 9th Circuit cases as follows: Roessert v. Healthnet, 929 F.Supp. 343 (N.D. Cal. 1996) (negligence claims against HMO and participating medical group not preempted). Moreno v. Health Partners Health Plan, 4 F.Supp. 2d 888 (D.Ariz. 1998) (direct and vicarious liability claims against HMO for creation of substandard care plan not preempted). Spain v. Aetna Life Ins. Co., 11th F.3d 129 (9th Cir. 1993) (wrongful death claims against plan administrator for failure to authorize procedure preempted). Toledo v. Kaiser Permanente Med. Group, 987 F.Supp. 1174 (N.D. Cal. 1997) (claims against HMO for breach of contract, fraud and infliction of emotional distress preempted). Schmid v. Kaiser Foundation, etc., 963 F.Supp. 942 (D. Or. 1997) (negligence and breach of contract claims against health plan alleging failure to perform tests and authorize treatment preempted). Medicare supplemental plans (preemption): Ardary v. Aetna Insurance Company, 98 F.3d 496 (9th Cir. 1996), cert. den. 520 U.S. 1251 (where benefit denial or delay results in separate injury or death claim is not "inextricably intertwined" with benefit determination process and damage is not compensable by after-the-fact reimbursement of plan benefits, therefore not subject to Medicare act exclusive remedies and not preempted). See also two cases currently pending in California Supreme Court on same or related issues, as follows: Levy v. PacifiCare of Calif. (S085550), previously unpublished, and McCall v. PacifiCare of Cal., Inc. (S082236), previously (1999) 74 Cal.App.4th 257. RICO Liability: Forsyth v. Humana, Inc., 525 U.S. 299, 119 S.Ct. 710 (1999) (under direct conflict test state law remedies for bad faith, including punitive damages, applicable to health plan can coexist harmoniously with remedies under RICO, including treble damages). Unfair Competition Act liability: See State Farm Fire & Cas. Company v. Superior Court (Allegro) (1996) 45 Cal.App.4th 1093 (statutorily prohibited or unfair business practices can provide a basis for liability under B & P §17200, including restitutionary relief). Private right of action under Health & Safety Code: Samura v. Kaiser Foundation Health Plan, Inc., (1993) 17 Cal.App.4th 1284 (no private right of action created by Health & Safety Code against health plans; but see new Civil Code §3428 cause of action, other statutory-based causes of action and common law causes of action, all of which may be available. CONCLUSION: The HMO industry is no doubt here to stay, but it is still in a transitional phase with all of the inherent instabilities normally associated with relatively young, immature industries. There continues to be a significant tension between the financial and business-driven practices of HMO's, on the one hand, and traditional statutory and common law legal duties and obligations, on the other hand, which may give rise to numerous causes of action and remedies. Likewise, at both the state and federal level there is ongoing change in regulation of HMO's as well as statute-based immunities and liabilities. Added to the mix of change and uncertainty is the changing analysis of, and consequent legal effect of, various preemption doctrines, such as those associated with ERISA and Medicare. The handling of HMO cases can be both complex and challenging. This paper is intended to provide a basic resource for the practitioner.
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