EXTERNAL REVIEW: Only One Company Steps Forward to Oversee HMOs
Despite a much-publicized California law that allows terminally ill patients to seek independent review for cases in which their HMOs refuse to pay for experimental treatment, only one company - - in Pennsylvania -- has filed a successful bid to provide reviews. HAYES Inc. "now has the final word whenever an eligible California patient" -- defined as a person "expected to live less than two years who [is] seeking coverage for procedures or treatments considered nonstandard" -- seeks an appeal of an HMO's decision to deny coverage. HAYES hires physicians from around the country to fill three-person appeals boards, which "determine the optimal treatment for each patient's situation." The San Diego Union-Tribune reports that, of the four cases HAYES has handled thus far -- all of which concerned cancer patients -- it has sided twice with patients and twice with HMOs.
More on the Way
The Institute for Medical Quality, a not-for-profit subsidiary of the California Medical Association, is charged with accrediting and monitoring case reviewers. Institute President Jill Silverman said that "a Maryland company will be surveyed next month for possible accreditation." She had expected "university medical centers to apply to be accredited," but was told that such institutions are loathe to assume the legal liability and are deterred by "the $10,000 application fee and rigorous standards." Dr. Jonathan Hake, who runs a cancer support group, also charged that the panels are biased because they hear testimony only from HMOs and doctors, who are "often employed by or under contract to the health plan." He said, "It's misleading. It's neither independent nor truly external."
Neutrality is Our Watchword
HAYES President Winifred Hayes said "her company is meticulously evenhanded," and although "most of its income comes from HMOs and other insurers ... the business is increasingly dependent on government regulation, with many safeguards ensuring impartial review." She added, "Our whole reputation is based on our neutrality. We have to be absolutely pristine." Hayes noted that unlike voluntary HMO appeals processes, which determine only whether treatments are experimental, HAYES panel members consider the patients' well-being first and foremost. Appeals must be handled within 30 days, or as little as one week if the patient's doctor says the review is urgent.
Just a Pilot?
The Union-Tribune reports that the California legislature will consider this year whether to expand the independent review program beyond cases dealing with experimental treatment to include "virtually everyone denied coverage for virtually any kind of treatment." On a national level, Congress is expected to debate similar legislation this year (Duerksen, 2/10).