CAHP: HMOs Voluntarily Institute Outside Reviews
In a move that marks the first time HMOs have "voluntarily" announced "key safeguards" for consumers, the state's HMOs said yesterday they would establish independent panels of doctors to review patient appeals, the Los Angeles Times reports. The California Association of Health Plans announced that several of its members "promised that if the experts agree with the patient, then [they] will provide the service." Walter Zelman, president of the CAHP and long-time consumer advocate, said, "This effort is aimed at addressing the single greatest fear that people have -- that in some critical circumstance they may be denied care that they may need" (Bernstein/Rubin, 12/3). The CAHP says that 16 of the state's largest health plans -- which cover more than 90% of the 20 million enrollees insured by CAHP's 40 members -- have agreed to adopt the practice (CAHP release, 12/2). The Washington Post reports that the "announcement attested to the pressure the managed care industry feels from patients and politicians pushing for tighter regulations." Zelman said, "This is in large part an acknowledgement (that) the public has legitimate concerns about managed care, and that plans want to address those concerns" (Hilzenrath, 12/3).
'Not Far Enough'
The San Francisco Chronicle reports that "[c]ritics immediately denounced the external review program," saying "it doesn't go far enough to protect patients' rights, since HMOs will still hire -- and possibly bias -- the reviewers." While state Assemblywomen Carole Migden (D-San Francisco) "praised" the CAHP's action, she said she plans to introduce legislation next week requiring outside review panels manned by doctors the state chooses. "We want to make sure the reviewers are independent," she said. The Chronicle reports that two HMOs -- Health Net and PacifiCare -- already offer outside reviews, while the rest of the HMOs "have set varying timetables to deliver on the promises ... made yesterday." Blue Shield of California President Bruce Bodaken said, "We will touch all of the consumers by the end of 1999, and most of the consumers will have this in place before that" (Abate, 12/3). Others criticized the voluntary measure saying it wasn't binding enough. The Clinton administration "praised" the move, but said voluntary measures don't carry the same weight as government mandates. Nicole Tapay, a professor of public policy at Georgetown University, agreed, saying, "What you lose with the voluntary system is government oversight."
The Times reports that there's still some skepticism about how the program will work. Each HMO "will set up its own appeals process," making it likely that consumers will "encounter confusing and perhaps even conflicting rules if they switch to a new HMO." Further, the Times notes that the new outside appeals process only applies to medical decisions -- patients "who have been denied a treatment that the HMO says is not covered, or who inadvertently fail to follow HMO guidelines in seeking treatment ... will continue to have little recourse." Consumer Union's Betsy Imholz said, "It's a very, very modest step, and maybe even a step in the wrong direction. Only the broadest questions have been answered." External review panels are still a consumer's last resort -- internal appeals processes must be exhausted first, the Times notes (12/3). Karin Caves, spokesperson for the Consumer Attorneys of California, said, "We consider external review a sham if consumers don't have the right to sue HMOs for denial of coverage." Migden "said Democrats will probably give consumers some form of right to sue HMOs as part of any HMO bills," but that "the only question would be how broad that right should be" (Chronicle, 12/3). Click independent reviews for past coverage of the issue.