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Law Will Boost Terminal Patients' Rights

Health: Wilson signs bill allowing review of cases by outside panel of doctors if insurers deny coverage for experimental treatments.


Gov. Pete Wilson on Friday signed into law a bill giving terminally ill patients who are denied insurance coverage for experimental medical treatments the right to have their cases reviewed by an independent panel of doctors.

Supporters said the bill is the first of its kind in the nation. The hotly debated legislation followed several highly publicized cases in which California juries handed down multimillion-dollar verdicts against HMOs for denying bone marrow transplants to women with breast cancer.

The bill, first introduced two years ago, drew broad bipartisan support after changes that limited its scope. It takes effect in July 1998.

The legislation addresses the contentious issue of experimental medical treatments, which virtually all HMOs and other health insurers refuse to cover. Up to now, patients who were denied a treatment either had to pay for it themselves or sue their health insurers.

Disputes are common, partly because there is often disagreement in the medical community over what constitutes an experimental treatment. Critics have accused health insurers of arbitrarily denying payment for costly experimental treatments.

Bone marrow transplants are routinely used to treat such diseases as leukemia and are increasingly being employed to treat breast cancer patients. Most doctors still consider them experimental for breast cancer, however.

Assemblywoman Barbara Friedman (D-Sherman Oaks), the bill's co-author, said she decided to sponsor the legislation in part because of her involvement in breast cancer issues.

"I was meeting women who had almost identical medical conditions whose doctors recommended bone marrow transplants," she said. "But they had entirely different experiences in getting treatment depending on what health plan they were in."

The legislation "will guarantee terminally ill patients that decisions on their treatment will be based on medical science, not on corporate profits," Friedman said.

At a ceremony in his office, Wilson said: "We're doing what's sensible by taking this final decision of treatment away from the government and courts and putting it where it belongs, in the hands of the medical experts."

The bill allows terminally ill patients--defined as those with two years or less to live--the right to seek appeals when they are denied experimental or controversial treatments. The appeals will be heard by a three-member outside panel of doctors. Their decisions will be binding on HMOs and other insurers.

Health insurers won a compromise providing that two of the three doctors must agree that a treatment is worthwhile before their decision is binding. A few health insurers, including Kaiser Permanente and Aetna, use outside panels to review appeals for experimental treatments.

The new law will not apply to recipients of Medi-Cal, the state-federal health program for the poor. It also will not cover workers who get their coverage through employer health plans that are exempt from state insurance regulations because they are self-funded.

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