DMHC Report Finds Managed Care Companies Prevail in 65% of Independent Reviews
Under new consumer protection laws enacted Jan. 1, an independent review board has heard nearly 200 disputes between managed care plans and patients, and the health plans have won 65% of the time, according to a report to be released today by the Department of Managed Health Care. The Los Angeles Times reports that the study "provides the first snapshot of how recent HMO reforms have affected access to care and the way that consumer complaints are handled." Since the independent review law took effect at the beginning of the year, the DMHC has sent 195 cases to an independent physicians' board for review -- 110 were decided in favor of health plans and 58 in favor of patients, with the remainder still pending. The Times reports that while consumer advocates have generally given the DMHC "good marks for responsiveness" to consumer complaints, the cases heard so far by review boards are a "minuscule fraction of the total complaints" the agency receives. Roughly 15,000 people call the DMHC monthly, with about 50% receiving an answer through an automated phone system. Most others generally get their complaints resolved within a few days, according to DMHC Director Daniel Zingale. Still, some cases are "trickier," and the department registers a "formal complaint," of which 3,228 were recorded last year.
The report also examined the complaints of consumers from about 50 health plans, and found that among insurers with more than 1 million members, Aetna U.S. Healthcare had the lowest rate at 0.67 complaints per 10,000 members, followed by the Kaiser Foundation Health Plan at 1.22. Health Net and PacifiCare had the highest rates of 2.3 and 2.52, respectively. Still, advocates say that "[w]ithout more data, it's unclear what these scorecards mean," as consumers may be taking their complaints to another state agency or may not know which department to contact with a problem. Noting that the DMHC has improved consumer services, Earl Lui, an attorney for Consumer Union, said, "The question is: Are consumers satisfied with the results. It's hard to know the answer to that without following up and asking the consumers what happened."
State officials and consumer advocates are hoping that the report will help shape the debate in Congress over a federal patients' bill of rights, which includes an expanded right to sue managed care companies, similar to the California law enacted in January. While opponents of such measures contend that they could lead to "frivolous lawsuits," the Times reports that state officials are "unaware of any such lawsuits since Jan. 1." Zingale said, "Certainly we have not seen that happen" in California, adding, "And I would say that California's [consumer protection] laws are among the strongest in the nation." Jamie Court, executive director of the Foundation for Taxpayer and Consumer Rights, said that the right to sue in California was "acting as a deterrent" against care denials and causing managed care companies to "giv[e] people what they want before they get to the external review." But Bobby Pena, a spokesperson for the California Association of Health Plans, said that the absence of lawsuits this year "demonstrates that the HMOs' internal review systems are fair and effective," adding, "[T]here's no need for the right to sue. For the most part, the numbers show that health plans are doing the right thing" (Carey, Los Angeles Times, 6/11).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.