U.S. Supreme Court Case to Determine Fate of California’s Independent Review Program
A U.S. Supreme Court case examining the validity of independent reviews for patients in managed care plans could "gut" California's patient protection laws if the court rules that employees cannot use state external review programs to appeal a denial of care and force their insurer to cover a disputed treatment, the Sacramento Bee reports. Department of Managed Health Care Director Daniel Zingale said that such a ruling "would be an unraveling of the core of California's patient bill of rights" (Rapaport, Sacramento Bee, 1/14). The case, to be argued on Wednesday, centers on whether state laws giving patients the right to outside reviews of insurers' treatment decisions are valid under the 1974 Employee Retirement Income Security Act, a federal statute that prohibits patient lawsuits against HMOs in state courts and limits damages in federal lawsuits to the cost of treatment that was denied. Thirty-eight states and the District of Columbia have laws that allow patients to demand an independent review in disputes with their health plans over denials of care (California Healthline, 1/11). In its first year, California's review program heard 613 cases, two-thirds of which were decided in favor of health plans. "Even so, the state must preserve the program to protect against HMO decisions that doctors believe are wrong," Zingale said, adding, "Ending our review program after such a successful first year is a bit like taking metal detectors out of airports on Sept. 12. It's removing a needed protection that saves lives" (Sacramento Bee, 1/14).
A San Jose Mercury News editorial states that it would be a "crying shame" if the "big insurers" fighting independent review laws succeed, as California's program is "exactly what [the state] needs: a way for doctors and patients to find fairness in the struggle with managed care." The editorial concludes, "No one tries to argue against the benefits of independent review boards. They clearly are a great idea, endorsed by Democrats and Republicans alike, including President Bush. Independent review helps patients because it ensures good medical judgment will prevail in disputed cases" (San Jose Mercury News, 1/13).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.