The case, Pegram v. Herdrich, concerned a woman whose appendix burst after she was made to wait eight days to take a diagnostic test for abdominal pain. She contended that her H.M.O., which, like many health plans, gave doctors financial incentives to hold down costs, improperly restricted patients' access to medical procedures.
The court's decision for the health plan made blunt comments about the role of H.M.O.'s in rationing care. Such rationing, the court said, is intrinsic to the design and mission of H.M.O.'s, blessed by Congress since 1973. Writing for a unanimous court, Justice David H. Souter said, ''No H.M.O. organization could survive without some incentive connecting physician reward with treatment rationing.''
Whatever the form of an H.M.O., ''there must be rationing and inducement to ration'' care, Justice Souter declared. Such inducements, he said, especially ''the profit incentive to ration care,'' go ''to the very point of any H.M.O. scheme.'' If plaintiffs could challenge such incentives in federal court, he said, it would open the courts to ''wholesale attacks'' on H.M.O.'s.
