CALIFORNIA: WILSON SIGNS PATIENT EXTERNAL APPEAL LAW
Gov. Pete Wilson (R) signed legislation Friday that willThis is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.
require health plans and disability insurers that deny coverage
for an experimental treatment to a terminally ill patient to
submit the decision to an independent review at the request of
the patient or the patient's doctor. The Friedman-Knowles
Experimental Treatment Act will provide a uniform process for
reviewing denials of coverage when standard treatments "have not
been effective or medically appropriate" (Wilson release, 9/27).
The external appeals mechanism was modeled after the Medical Care
Ombudsman Program of the Bethesda, MD-based Medical Care
Management Corporation. According to Medical Care Management,
less than one-half of one percent of the cases it has reviewed
have proceeded to litigation (Medical Care Management release,
FIRST OF ITS KIND: Wilson said, "[W]e are taking a landmark
step toward making our health care system even more fair and more
responsive to the concerns of the desperately ill. Under this
new law, California becomes the first state in the nation to
create an automatic appeals process for patients denied
experimental treatment by an HMO or disability insurer." He
added, "We're doing what's sensible by taking this final decision
of treatment away from the government and the courts and putting
it where it belongs -- in the hands of the medical experts"
(Wilson release, 9/27). According to Medical Care Management,
the new law is the "most comprehensive" of its kind in the
country, and "is expected to set a trend to establish patients'
rights in the emerging era of managed care" (Medical Care
Management release, 9/27).
DETAILS: Under the law, the state commissioner of
corporations will have to contract with a private, nonprofit
accrediting organization that will accredit independent review
entities by January 1, 1998. Health plans and other insurers
will be required to contract with these independent review
entities by July 1, 1998 (Wilson release, 9/27).