For the California Department of Managed Health Care, the honeymoon is over.
A consumer group’s petition to make public records of HMO arbitration hearings sparked outrage from health plans and will force department director Daniel Zingale to step into a dispute with few easy answers.
The petition, filed Tuesday, gives Zingale 30 days to decide if he wants to expand HMO regulations to require health plans to disclose all documents and discovery obtained during arbitration.
Such records currently are not made public.
The groups behind the petition are the Foundation for Taxpayer and Consumer Rights and the Health Administration Responsibility Project.
They are concerned about the nearly 24 million Californians required by HMOs to resolve health care disagreements through binding arbitration. Access to records of past proceedings would give patients an edge in negotiations with health plans, the petition says.
Not so, says the California Association of Health Plans. It argues that disclosing arbitration documents raises serious privacy and liability issues and would ultimately make settlements more difficult to achieve.
Nobody questions that patients often are confused about their rights under managed care. But opinions abound on how patients might benefit from access to arbitration records.
At its heart, the mission of the new managed care department is to protect patient rights in disputes with HMOs. On the surface of things, all Zingale has to do is make a decision that is in the best interests of consumers.
But this may be easier said than done, observers say.
In keeping with the cautious, deliberative approach to government favored by Gov. Gray Davis, who appointed him, Zingale said there’s a lot he needs to research before he makes up his mind.
“What we’re most interested in right now is finding out how health plans are using results of arbitration to improve care for all patients,” Zingale said. “We don’t have information on that.”
A recent report on HMO arbitration by the California Research Bureau, the arm of the State Library that conducts studies for legislators, said many health plans are failing to report arbitration results, as required by law.
The 171 arbitrations reported to the state between March 1999 and April 2000 fell far below the 300 estimated proceedings during this period, the report found.
Walter Zelman, president of the California Association of Health Plans, challenged the report’s findings and called it misleading.
“The numbers of arbitrations that take place in California are almost in the single digits, and there’s no evidence to suggest that health plans are depriving patients of their rights,” he said.
Such disputes over the number of arbitrations or their outcomes could easily be eliminated simply by making the records public, said Jamie Court, executive director of the Foundation for Taxpayer and Consumer Rights.
“It would give the public and the state a tool to judge the seriousness of allegations against HMOs and determine how credible the arbitration process was,” Court said.
While such information may well help Zingale and others in the state figure out how to best regulate managed care plans, some health care experts say patients already unsure of their right to challenge HMO decisions may not be able to decipher records once they have them.
A recent Henry J. Kaiser Family Foundation study of HMO consumers found that only 6 percent of patients with a dispute filed a formal claim with their health plan or with an external official.
One Kaiser Permanente patient said he felt as though he needed a lawyer just to figure out whether doctors were negligent in repeatedly misdiagnosing his life-threatening heart condition.
“They make it so damn tough for people to find out what their rights are and what to do about it,” said the 67-year old man, who asked not to be identified. “Not all people are college graduates, and all this arbitration and going to court, that’s up in the sky for me.”