HMO 3rd Party Review System Fails CA

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In California, “independent” external review has proven to be anything but independent, while failing managed care patients. The Friedman-Knowles Experimental Treatment Act was mandated in 1996 for patients in need of “experimental procedures” when “standard therapies would not be medically appropriate for the enrollee.”

  • So far only one agency has been accredited to handle reviews, and was accredited only just this February 1999, although the law was supposed to take effect in July 1998. Other review agencies have been unable or unwilling to prove their independence and efficacy to handle such reviews, which is required by law.
  • The dearth of “independent” reviewers suggests there are no such thing as truly independent review agencies, or at least that a jury is as close as one gets to an independent reviewer and two hundred years of jurisprudence is as close as one gets to an independent review.

The test case for California’s “independent” review system must lose her home to get life-saving treatment. Barbara Brown, once a teacher of the year, had contracted advanced ovarian cancer. On July 1, 1998, she was the first person to appeal under the Friedman-Knowles Act., and her case highlighted the fact that HMO corporations have the upper-hand in their disputes with patients.

  • Barbara found that there was not a single accredited independent reviewer in the state, though the legislation was enacted in 1996. With no independent reviewers available, the HMO was allowed to select the panel that reviewed Barbara’s case.
  • Denied life-saving treatment by both her HMO’s internal grievance process and so-called external review, Barbara was forced to sell her house to pay for the treatment, which she received in the beginning of August 1998. Only a community bake sale that raised $25,000 provided the down payment for Barbara’s care. But Barbara recovered quickly as her “experimental” surgery, which the HMO said would kill her, resulted in the surgeon being able to completely remove all visible tumors from her abdomen.

According to Barbara Brown, and records obtained by her, the review was anything but “independent.” Barbara testified before the California Assembly Judiciary Committee in August 1998 to oppose new HMO industry-backed legislation for external review, calling the model Friedman-Knowles system neither “independent,” nor consumer-friendly.

  • In her remarks, Barbara stated “[The HMO] has thoroughly and deliberately undermined the avowed intention of this Act…First, [the HMO] made every effort to control all the information that went into the review processÖSecond, [the HMO] biased the panel of experts against my proposed experimental therapy by steering the experts toward [the HMO’s] own leading set of questionsÖThird, in their reports, the experts all stated that their assigned role was to respond to [the HMO’s] questions, rather than to perform a truly “independent medical review.” All of these statements depict behavior by the HMO that explicitly violates the mandates of the Friedman-Knowles Act and defeats the whole purpose of having a truly independent, external review.

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