COMMENTARY: One for the patients: Court backs states on allowing second opinions on health care

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Philadelphia Inquirer

The following editorial appeared in the Philadelphia Inquirer on Friday, June 21:

Just when the anti-HMO movie “John Q” was well on its way to the bottom shelves of video stores, along comes the Supreme Court to bolster Americans who have a simmering feud with managed-care insurers.

The court, though heavily divided, has given medical patients a reason to cheer — handing them a victory Thursday that preserves their appeal rights when HMOs deny care.

The court ruled in the case of an Illinois health maintenance organization that refused to pay for a suburban Chicago woman’s $95,000 operation to remedy a rare, debilitating nerve problem.

In this real-life drama, the patient, Debra Moran, triumphed — but only after she used her life savings to pay for the operation. She finally got her health plan to pay by using Illinois’ patient-rights law, which gave her a right to a second opinion. Illinois is one of dozens of states with similar statutes.

But the HMO, Rush Prudential HMO Inc., since purchased by Wellpoint Health Network, challenged in court. It questioned whether states even have the right to offer such protections. Result: A classic Goliath v. David confrontation.

In upholding the Illinois law, Justice David Souter, writing for a five-vote majority, in effect said federal law did not preclude states from giving patients the right to second opinions through an independent appeals process.

That’s certainly good news for managed-care patients, who should be able to look to independent reviewers to hold insurers accountable for coverage decisions.

Was the Illinois case a challenge to all such laws on patient appeals? Not literally, but there’s no question it was a key test of the concept. Said one health-care activist, Jamie Court of the Foundation for Taxpayer and Consumer Rights in California, “If one justice had decided differently, the entire state scheme of HMO regulation would have unraveled. This case had the potential to undue all the hard-earned gains of the HMO patients’ rights movement.”

Managed-care insurers, for sure, weren’t happy. While most have implemented their own review processes for patients, they were looking for the court to strike down the Illinois law. But don’t just fit the managed-care companies for a black hat. It’s not that simple.

Their contention, and it’s on target, is that Congress should enact uniform, national patient-protection measures. They suggest that a ruling against Ms. Moran could have forced Congress to break the political and ideological gridlock that’s kept a patients-rights bill bottled up.

Trouble is, there are plenty of roadblocks to a congressional patients’ bill _ not least, insurers’ own fierce opposition to giving patients the right to sue HMOs.

Congress needs to act, no question. But without the immediate prospect of a federal patient law, the Supreme Court has done well in backing states’ efforts to heal patient-HMO rifts.


(c) 2002, The Philadelphia Inquirer

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