Patient Advocacy and Termination from Managed Care Organizations: Do State Laws Protecting Health Care Professional Advocacy Make Any Difference?

I. Introduction . . . . . 510 II. A Road Map . . . . . 512 III. What Is Advocacy? . . . . . 513 A. Fiduciary Duty . . . . . 513 B. Health Care Professionals’ Viewpoint . . . . . 515 C. Common Law Views on Health Care Professionals Duty to Advocate . . . . . 516 D. Advocacy - A Problem of Definitions . . . . . 519 E. How Common Is Health Care Professional Deselection? . . . . . 522 F. National Health Care Professional Data Banks . . . . . 525 IV. Statutory and Common Law Protections for Health Care Professionals Who Advocate for Their Patients . . . . . 527 A. Legislative Action . . . . . 527 1. Explicit Protection of Advocacy . . . . . 527 2. Implicit Protection of Advocacy . . . . . 532 a. By Statutes . . . . . 532 i. Prohibition of Retaliation Based on Rendering Mandated Services . . . . . 532 ii. Statutes Prohibiting “Gag Clauses” . . . . . 534 iii. Statutes Establishing Procedural Due Process for Health Care Professionals . . . . . 535 iv. Statutes Prohibiting Financial Incentives to Control Costs . . . . . 540 b. Other Statutory Protections for Advocacy . . . . . 541 B. Common Law Protection for Advocacy . . . . . 542 1. Fiduciary Duty to Advocate . . . . . 542 2. Implied Covenant of Good Faith and Fair Dealing . . . . . 544 3. Common Law Right to Fair Procedure . . . . . 546 4. Additional Common Law Theories . . . . . 547 V. Barriers to Enforcement of Advocacy Protection Laws . . . . . 550 A . Federalism . . . . . 550 1. ERISA Preemption . . . . . 550 2. Medicare Managed Care Preemption . . . . . 562 3. Procedural Enforcement Obstacles . . . . . 564 a. Does the Statute Create a Private Cause of Action? . . . . . 564 B. Burdens of Production and Persuasion . . . . . 567 C. Discovery . . . . . 570 1. Practical Burdens of Litigation . . . . . 572 VI. How Effective Are Advocacy Protection Laws – Is More Needed? . . . . . 573