Bureaucrats’ Budgets Can Trump Doctors’ Orders, U.S. Court Rules

Published July 1, 2009

A panel of the 11th U.S. Circuit Court of Appeals in Atlanta, Georgia has ruled treating doctors do not have final say when determining how much care a state provides to Medicaid patients.

The decision overturns an earlier ruling from a U.S. district court holding the state could not reduce doctor-ordered care.

Rationing OK’d

The case involved a Georgia child disabled by a stroke while in utero. She has chronic conditions including mental retardation and cerebral palsy and suffers from seizures and respiratory problems.

A doctor ordered 94 hours a week of home-health nursing for the girl. In 2007 the state Department of Community Health, which operates the program that administers Medicaid funding for nursing services, approved the Georgia Medical Care Foundation’s request to reduce that care to 84 hours for budgeting purposes, according to court documents.

U.S. District Judge Thomas W. Thrash Jr. ruled in June of last year the reduction in hours was improper and the state was obligated to provide the treatment the child’s physician recommended.

Georgia appealed Thrash’s ruling on behalf of Medicaid managers who said the ruling stripped them of necessary flexibility and discretion in allocating Medicaid resources. The state maintained federal regulations allow Medicaid agencies to place limits on services based on “medical necessity.”

Attorneys for the child argued federal law requires state Medicaid programs to provide care to “correct or ameliorate defects and physical and mental illnesses” for low-income children.

Doctors Slammed as Irresponsible

In an amicus brief filed on behalf of Florida and Alabama, Justin Senior, acting general counsel for Florida’s Agency for Health Care Administration, argued the district court’s ruling in favor of providing the full doctor-prescribed treatment “would essentially invalidate a Florida statute and prompt a drastic shift in Medicaid funds … into unproven, unnecessary, ineffective, cosmetic, and dangerous treatments for persons under 21.”

Senior wrote, “Treating physicians … cannot be trusted with this sort of decision. … When left to their own devices, they advocate for their patients and deem all manner of unproven, dangerous, ineffective, cosmetic, unnecessary, bizarre and controversial treatments as ‘medically necessary.'”

Virginia Fuller, Georgia’s assistant attorney general, told the appeals panel Thrasher’s order would result in private physicians having “unfettered discretion to spend public money.”

In its court brief, Georgia argued nursing hours can be decreased if the patient’s medical condition is stabilized. However, attorneys representing the patient argued the state’s weaning of patients from nursing services does not follow federal standards.

Government Overreach Blamed

“When a government system can’t afford to pay for the services it has promised, such as Medicaid, the result is that care is rationed by waiting, care is rationed by simply denying certain services, or, as only government can do, it simply pays providers what it wants, even if it is less than the cost of the service,” said Kelly McCutchen, executive vice president of the Georgia Public Policy Foundation. “Of course, these costs are just shifted to the private sector.

“Many countries even make it illegal for citizens denied health services to pay for those services with their own money,” McCutchen added.

David A. Webster, the child’s legal aid attorney, said in a release, “The decision has little meaning because it does not clarify the relationship between the state and the physician, which means further litigation will seek to clarify this point of law.”

“This case should give pause to those who support socialized medicine, because this is exactly what happens when government controls health care decisions rather than physicians” being allowed to do so, said McCutchen.

Sarah McIntosh ([email protected]) teaches constitutional law and American politics at Wichita State University in Kansas.

For more information …

Moore v. Medows, 11th U.S. Circuit Court of Appeals: http://www.ca11.uscourts.gov/unpub/ops/200813926.pdf