State HMOs Will Allow Independent Appeals
Concerned that powerful regulation of their industry is at hand, California's HMOs on Wednesday gave consumers a key safeguard, allowing those who are denied care to appeal to an independent panel of doctors for what amounts to a binding second opinion.
Once the panels are up and running, a patient who wishes to undergo a particular treatment--a CAT scan, say, or a bone-marrow transplant--but is turned down, may turn to one of these panels of experts. The HMOs and managed-care firms, all members of the California Assn. of Health Plans, have promised that if the experts agree with the patient, then the companies will provide the service.
The program, by 22 companies serving almost 20 million Californians--including nearly all of the 17 million enrolled in HMOs--is essentially the first move in what is likely to be a long and intricate political game, as emboldened Democrats make plans to reform health care at both the state and national levels.
The announcement comes at a time when the image and financial condition of HMOs and other managed-care companies could hardly be worse. Consumers and politicians have roundly criticized managed care for denying needed treatments and, in several dramatic recent cases, dumping thousands of elderly patients from Medicare HMOs.
Many companies are either losing money or bringing in profits of less than 2%, and most have raised premiums. In New Jersey, HIP Health Plan--the state's fourth-largest HMO--failed spectacularly in October and was taken over by regulators.
The California plan, which is part of a nationwide effort to improve the industry's tattered image, was praised by the Clinton administration, but officials cautioned that a voluntary program would not provide consumers with the same assurance as one backed by the force of state or federal law.
"This is a welcome first step but it doesn't go far enough," said a senior White House health-policy official. "The president believes that all patient protections included in the patients' bill of rights, including a strong enforcement mechanism, should be provided in every health plan."
California's health-maintenance organizations are the first in the nation to voluntarily announce such a program.
The American Assn. of Health Plans, which represents more than 1,000 plans nationally--including those in the California association--is considering following California and adding to its code of conduct a requirement that member plans allow patients to obtain an independent review of medical decisions, said Susan Pisano, a spokeswoman for the trade association.
