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The Daily News of Los Angeles

In a victory for patients and a serious blow to the managed-care industry, a closely divided Supreme Court ruled Thursday that states can now force health maintenance organizations to pay for treatments they initially reject.

The court’s 5-4 decision allows patients to bypass health-plan
gatekeepers who determine the fate of a treatment’s payment, while alleviating pressure from Congress to pass a national patients’ rights plan. The court’s proceedings also define a pivotal shift in power, with patients regaining control of the care HMOs once appeared to dictate.

“This reaffirms that patients should be entitled to decisions being made based on their specific needs and not on a contractual basis,” said Dr. Vincent Riccardi, president of La Crescenta-based American Medical Consumers.

In California, patients already have access to such a process. Patients can also collect damages from HMOs whose interference with care significantly harmed their well-being. When a patient or a doctor requests a second opinion, the health care plan must quickly provide a second opinion by a qualified health care professional, according to the Santa Monica-based Foundation for Taxpayer and Consumer Rights.

The Supreme Court’s ruling validates the rights Californians have
already been entitled to, despite little acknowledgment from HMOs. Though the ruling provides evidence that HMOs are coming under greater scrutiny by the government, “it doesn’t get us any further into the judicial review process,” said Jamie Court, executive director of the foundation.

If the Supreme Court’s ruling didn’t pass, California would have had a difficult time justifying its own policy toward HMOs. The ruling comes several months after patients’ rights legislation stalled at the Capitol, putting on hold plans for a nationwide system for independent evaluations, reports said.

With the court’s decision potentially affecting more than 70 million Americans, managed-care companies don’t seem concerned. “This (independent review) is already our standard practice,” said David Olson, a spokesman for Woodland Hills-based Health Net. “If there is any question about medical necessity, this is how it should work.”

As for the court’s ruling, Olson said he didn’t think it was necessary because the policy of entitling a patient to a second opinion has already been in place throughout the country. “The ruling is more of a hyper-technical thing,” he said. Health Net shares fell 74 cents, or 2.6 percent, to close at 28.11 Thursday.

HMOs have argued that they were not opposed to independent review boards, but would prefer a national standard instead of several different state laws. Thursday’s ruling stems from the Illinois procedure used by Debra Moran to get her health plan to pay for a debilitating nerve problem. The court filing said her surgery had cost about $95,000.

The court said the Illinois statute doesn’t have to bend to a federal law that determines employee benefit plans. The court ruled against Moran’s health carrier, Rush Prudential HMO Inc., which is owned by Thousand Oaks-based WellPoint Health Networks. WellPoint acquired Rush Prudential in March 2000. WellPoint shares declined $1.93, or 2.2 percent, to close at $84.27 Thursday.

“We view this ruling as providing clarity,” said Ken Ferber, a WellPoint spokesman.

Ferber didn’t say whether the ruling could potentially lead to higher premiums. But the Health Benefits Coalition said in a statement that “by forcing employers and health plans to adhere to potentially 50 different conflicting state external review requirements, the court has already dealt a blow in the battle to control the already soaring cost of health care for working families.”

Still, the number of cases in which patients ask for an independent
review are very small. In 2000, about 2,500 cases were accepted for full review in 16 states surveyed by the American Association of Health Plans. The reviewer upheld the decision made by the insurer’s doctors in about half of those.

“And most disputes are resolved before you get to this point,” said Jim Anderson, a spokesman for Oakland-based Kaiser Permanente. Anderson also said the court’s decision won’t even affect California because those laws already exist in this state.


A list of situations in which a health plan must authorize a second

–Questions about the reasonableness or necessity of a recommended surgical procedure.

–Questions about a diagnosis or plan of care for a condition that
threatens loss of life, limb, or bodily function, or a serious chronic condition.

–A diagnosis that is in doubt due to conflicting test results, the
patient’s doctor is unable to diagnose a condition, or the clinical indications are complex, unclear or confusing.

–The treatment plan in progress is not improving the patient’s condition.

–The patient attempted to follow a plan of care and has serious concerns about the diagnosis or plan of care.

The Foundation for Taxpayer & Consumer Rights

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