Don’t Let HMOs Privatize Reforms

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Opinion Editorial by Jamie Court

San Diego Union-Tribune

Should the life-and-death appeals of HMO patients really be in the hands of private reviewers who are hired by the HMO and use private protocols to reach their decisions?

Privatization advocates have long tried to turn public control of our schools, courts, public assistance systems and municipal services over to private corporations in the name of greater efficiency. But this week, Aetna, and other of the nation’s largest HMOs, have actually tried to privatize legislative reforms of their own industry by promising to implement private ” independent” review systems, where the HMO voluntarily pays a third party to review patient problems, rather than submit to public mandates.

State and federal legislators cannot trust the HMO industry’s promise to reform itself through private efforts. Nowhere can the perils of privatization as a substitute for public accountability be seen more clearly than in the HMO’s reliance on independent review systems, which purport to give patients facing delays and denials an appeal but deliver far too infrequently.

First, the universe of reviewing companies are hardly “independent” of the HMOs that contract and pay for their services. For instance, marketing communications from one such company, Medical Care Management Corp. of Bethesda Md., to HMO clients boasts that the company “can save payors millions of dollars a year on just a few cases.

Our expert physicians affirm the high cost, high-risk procedures submitted for review in one-half to two-thirds of cases, depending on the type of disease and the patient’s profile. If you are paying for 100 such cases now, inadvisable treatments may be costing you over $6 million.”

California actually already enacted an independent review system in 1996 for patients in need of “experimental procedures” when standard therapies do not work. In theory, this independent review system was unassailable, but in practice not a single reviewing agency has been accredited to perform reviews under the law, which was to start July 1, 1998. No company has been able or willing to prove their “independence” through detailed disclosure about their financial ties to HMOs, their protocols and their reviewers.

Appeals decided by such companies are the HMO industry’s reform of choice because the private process permits bureaucratic maneuvers by HMOs that a seriously ill patient has neither the time nor capacity to defend against.

Folsom resident Barbara Brown, once a teacher of the year, ran up against these problems when she contracted advanced ovarian cancer and standard treatments would not do. On July 1, 1998 she appealed under the Friedman- Knowles Experimental Treatment Act. With no accredited reviewers, Kaiser picked an agency of its choice, Medical Care Management Corp.

Brown says, “First, Kaiser made every effort to control all the information that went into the review process. Second, Kaiser biased the panel of experts against my proposed experimental therapy by steering the experts toward Kaiser‘s own leading set of questions. Third, in their reports, the experts all stated that their assigned role was to respond to Kaiser‘s questions, rather than to perform a truly independent medical review.”

Denied life-saving treatment by both Kaiser‘s internal grievance process and then its so-called external review, Brown was forced sell her house to pay for her treatment. Only a community bake sale and car wash that raised $25,000 provided the down payment for her care. But Brown is recovering quickly, as her “experimental” surgery, which her HMO said would kill her, resulted in the surgeon being completely able to remove all visible tumor from her abdomen.

Private review systems are no substitute for civic scrutiny — such as a court of law. Congress and the Legislature must not be deterred from right- to-sue legislation and other public mandates, or the fate of mothers like Barbara Brown will continue to be decided at car washes and bake sales rather than by the imposition of public values on private corporations.

Third-party review systems only work well in conjunction with public laws for HMO accountability, when companies know that if they don’t play fair, they will face large damage awards or other fines. Texas’ independent review process, for instance, has been held out as successful, but Texas is also the only state in the nation where a patient can take an HMO in state court for quality of care violations, like she can a doctor. The independent review and liability laws were passed simultaneously.

A private system of appeal without ultimate public accountability is destined to betray the HMO patient. Legislators who forget their public mandate to reform HMOs and favor of a private solution would be doing their constituents a grave disservice.

Court is director of Consumers For Quality Care, a project of the Santa Monica-based Foundation for Taxpayer and Consumer Rights. He can be reached via e-mail at [email protected].

Consumer Watchdog
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