WASHINGTON — Before quitting for the summer, the Supreme Court said Friday it will decide next term whether states can set up independent panels of doctors with the legal power to review the medical decisions of HMOs.
The question is at the heart of the current debate over the patients' bill of rights in Congress.
If lawmakers do not resolve the issue by passing a new law this summer, the justices will take it up when they return to the bench in the fall.
Advocates for patients say the administrators of health care plans should not have the exclusive power to decide what medical treatments will be provided.
HMOs appear to have that authority now. Thanks to past rulings by the high court, patients who are unhappy with their HMOs' decisions cannot sue the plans for damages. The justices have interpreted a 1974 pension law as shielding "employee benefit plans" from being sued.
Undeterred, many states adopted a fallback approach that gives disgruntled patients the right to appeal when their HMOs deny them treatment. Typically, a panel of three doctors is entrusted to review cases. If they agree the treatment was medically necessary, they can order the HMO to pay for it.
Last year, then-Texas Gov. George W. Bush cited his state's independent review board as an example of the right way to balance the rights of patients and the responsibilities of HMOs.
California and 36 other states have adopted these independent review panels. But the legality of the independent review boards has been put in doubt.
Lawyers for the health insurance companies in Texas went to court there to challenge the state's power to establish these boards. They argued that the 1974 federal pension law shielded their plans from state interference.
In June 2000, the U.S. 5th Circuit Court of Appeals in New Orleans agreed, saying the state did not have the authority to oversee HMOs. The appellate judges cited the Supreme Court's ruling that shielded HMOs from all state laws.
In October, however, the U.S. Court of Appeals in Chicago came to the opposite conclusion. The Illinois ruling came in the case of Debra Moran, who had consulted her HMO doctors for severe pain in her shoulders and numbness in her limbs. They recommended physical therapy; she went to a specialist who recommended surgery instead.
