HMO REFORM: Sacramento Bee Backs Right To Appeal
An editorial in yesterday's Sacramento Bee notes that the California Legislature is "faced with choosing whether to improve protections for members of health plans or to protect malpractice lawyers who wish to exclude from court evidence favorable to the HMOs." Three bills (SB 1653, SB 1504, and AB 1667) before the state Legislature "would establish the right of HMO enrollees in certain circumstances to appeal denials of treatment to experts outside the HMOs." The Bee contends that such a system "would be a much-needed confidence booster to the 14 million Californians in HMOs, many of whom worry that plans will place profits over patient care when it comes to treatment decisions."
Current California law allows patients to appeal insurance company treatment denials through the HMO's internal review, which according to the Bee, "can be rigged heavily in favor of the HMOs and their contracted medical groups, the doctors who actually shoulder much of the financial risk." If after 60 days, the patient still wants to contest a claim, they can seek help from the California Department of Corporations, the regulator of the industry. But according to the Bee, the "department has neither the staffing nor the expertise to promptly resolve medical complaints." In the past, HMOs "blocked a fairer appeals process, unconvincingly arguing that existing regulations were adequate," but since consumers and lawmakers have lashed out against managed care, "the California Association of Health Plans has reversed course" and backed SB 1653, one reform plan proposed by state Sen. Patrick Johnston (D-Stockton).
Resolving Important Differences
The Bee points out that "important yet resolvable differences" remain between the three bills, such as: "How long should enrollees seek to resolve their complaints within an HMO before qualifying for the external review process? Should the Corporations Department or the HMO pick the certified outside reviewer? Should seniors in Medicare HMOs and the poor in Medi-Cal HMOs be eligible as well? And should this process be available for any dispute or only those with treatments that cost a certain amount of money?" The Bee editorial concludes: "Given the HMO's willingness to accept reforms, a compromise is within reach. The inevitable result would be happier, healthier patients with stronger protections. That is a worthy goal. Even for malpractice lawyers" (5/5).