WASHINGTON — Pamela Popp has an interesting take on the patients' bill of rights.

        As a registered nurse, she's seen patients frustrated by health maintenance organizations that limit access to specialists and ration care. As a lawyer, she defends doctors against malpractice claims.

        But she is not sure, with the high cost of health care, that giving patients an expanded right to sue their HMOs will solve much of anything.

        “I think that more important than the right to sue is the right to get a timely review of a medical decision,” said Ms. Popp, a lawyer with Greenebaum, Doll & McDonald in Covington.

        As Congress nears an end to a three-year debate on patients' rights, misgivings like Ms. Popp's are not uncommon. Lawmakers, under extreme lobbying pressure from interest groups, are trying to balance the claims of patients, doctors, HMOs and businesses in what has been a maddening puzzle.

        The Senate approved a bill Friday, 59-36, that would increase patient access to specialists and clinical trials and allow patients to appeal medical decisions to an independent review board. Patients still unsatisfied after a review could sue their HMOs for damages.

        A House version of the bill endorsed by Republican leaders and President Bush also would enhance patient access to medical care but would not be as generous when it comes to lawsuits.

        After an independent review, patients would have

        the option to sue HMOs in state court over medical decisions if an HMO refused to abide by a review board's findings.

        Patients could sue HMOs in federal court over a coverage decision and recover unlimited economic damages, but noneconomic damages, such as compensation for pain, would be capped at $500,000, and patients would not be able to seek punitive damages.

        President Bush told lawmakers last week that he would veto any legislation he felt would cause too many lawsuits and escalate health-care costs.

        “We do not want more uninsured Americans,” said Sen. Mike DeWine, R-Ohio, who negotiated portions of the Senate bill in consultation with the White House and Republican leaders. “We do have to do everything we can in this bill to try to protect employers from lawsuits while at the same time giving employees the right to sue their HMOs in limited circumstances.”

        The Supreme Court has ruled that under existing law patients cannot sue HMOs in federal court over complaints about medical coverage, finding that HMOs were created specifically to reduce health-care costs by setting medical priorities.

        The court held that patients could sue HMOs in state court over medical decisions, but most health-care providers attempt to move the cases into federal court as insulation from liability.

        Forty-two states — including Ohio, Kentucky and Indiana — already have laws allowing patients to appeal medical decisions to an independent review board, the National Conference of State Legislatures has found.

        Eight states permit patients to sue an HMO or other health-care provider in state court after patients exhaust all provider and independent appeals.

        Two years ago, Ohio went through a debate similar to the one in Congress when the state legislature granted patients the opportunity to appeal medical decisions but rejected new rights to sue HMOs.

        In the first year of the Ohio patients' rights law, 100 medical appeal cases have been closed by independent review, with 50 appeals decided in favor of the health care provider, 34 reversed in favor of the patient, 11 partially reversed and five withdrawn, according to the Ohio Department of Insurance.

        The department's consumer service division has judged another 189 cases involving contractual disputes, such as whether a medical procedure is covered under a health plan, with 122 appeals decided in favor of the provider, 36 reversed for the patient, 13 partially reversed, three withdrawn and 15 referred for further review.

        The same forces — doctors, lawyers, health care providers and businesses — that haggled over every detail in Ohio have made negotiations even more intractable nationally.

        The American Medical Association and the Association of Trial Lawyers of America, tapping into the public's dissatisfaction with HMOs, are asking Congress to give patients broad rights to counter the institutional power of their employers and health-care providers. The Health Insurance Association of America, the U.S. Chamber of Commerce and the National Federation of Independent Business are warning lawmakers that lawsuits will push health-care costs higher and lead some businesses to cancel health insurance for employees.

        The Health Benefits Coalition, an advocacy group for health plans and businesses, estimated that some versions of the bill would cause 1.3 million workers to lose their health insurance, including more than 55,000 workers in Ohio.

        Many Republicans agree with these predictions, but also have decided that much of the public wants Congress to adopt a bill that provides some legal recourse.

        Rep. John Boehner, R-Ohio, said lawmakers should settle on legislation that “protects patients and holds HMOs accountable for medical decisions while rejecting the path of unlimited, frivolous lawsuits that will only benefit trial lawyers, not enhance patient care.”

        Rep. Rob Portman, a Terrace Park Republican who is working with the White House on the issue, said Republicans understand the political climate but will not agree to give patients an unlimited right to sue HMOs or their employers.

        “People want to end up getting better care,” he said. “They don't want to end up in court.”

        Lawmakers likely will shield most businesses from legal exposure by allowing executives to select a single decision-maker, most likely the health-care provider, as the final word on medical decisions.

        Susan Laffoon, vice president of government and community affairs at the Greater Cincinnati Chamber of Commerce, said potential lawsuits would add more risk to businesses that voluntarily offer health insurance for workers.

        “Employers are trying to do the right thing by providing health coverage,” she said.

        Ms. Popp, the registered nurse and lawyer, said any new patient rights would likely come at a cost to the health-care system.

        “Where's that cost going to be felt?” she asked. “Well, you and I know where it's going to be felt.”

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