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California Department of Managed Health Care Director Daniel Zingale said yesterday that patients’ rights legislation (HR 2563) approved by the U.S. House last week “would undermine” the state’s review procedures for HMO consumers that took effect in January, the Los Angeles Times reports. “Californians now finally have a place they can turn to when they hit a wall with their HMO and they think economic interests are getting in the way of patient care, which so often happens with enrollees and HMOs. The House bill appears to pull the plug on that,” Zingale said (Ornstein, Los Angeles Times, 8/6).


Under California’s patient protection laws, managed care consumers have the right to seek an independent medical review if an HMO denies treatment by submitting an oral request to the state. Health plans pay for the costs of these reviews, which range from $395 to $25,000. If the patient is dissatisfied with the review panel’s decision, he or she can sue in state court, with no limits on damages (Rapaport, Sacramento Bee, 8/6). Under the House legislation, however, all “non-indigent consumers” would have to pay up to a $25 fee and file a written application — if requested by the HMO–for an independent medical review. And whereas the California law allows the DMHC to select members of the medical review boards, the House bill would allow the health plan to choose medical experts. The House measure also would place a $1.5 million cap on non-economic and punitive damages (Los Angeles Times, 8/6). According to Zingale, since January, when the California laws took effect, 300 patients have requested reviews, 60% of which have been decided in favor of the health plans (Gornstein, AP/San Jose Mercury News, 8/6). Zingale said he favored patients rights’ legislation approved by the Senate in June, which would place a $5 million limit on punitive damages and would not cap pain and suffering damages (Chiang, San Francisco Chronicle, 8/6). He also said that the Senate bill would not “supersede” California law, noting that it has an opt-out provision for states that can demonstrate that their rules “meet or exceed federal law.”


According to Jamie Court, executive director of the Foundation for Taxpayer and Consumer Rights, both the House bill and the Senate bill would extend patient protections to more than five million Californians who do not fall under the state review procedures because their employers are self-insured. However, the House bill would “take rights away from about 20 million Californians,” he said. California Association of Health Plans President Walter Zelman said that the organization did not support a weakening of the state’s independent review process. “It would be unusual to see the federal government preempt state law in this area and not allow states to enact stronger measures. We’ve accepted the California law here and did from the beginning,” he said (Los Angeles Times, 8/6). However, CAHP spokesperson Bobby Pena said that the group approved of the lower cap on punitive damages in the House bill. He also predicted that California consumers would not be significantly affected if the House measure became law, saying, “In principle the rights will remain consistent” (San Francisco Chronicle, 8/6).


A Houston Chronicle editorial highlights the “dispute” in Texas among lawmakers and interest groups over whether legislation passed in the House would “trump” patients’ rights laws in that state and other states. According to the editorial, the American Medical Association warns that the bill would “weaken” Texas law, and Rep. Martin Frost (D-Texas) has said that the legislation may “preempt” state patient protections, including independent review of disputed HMO claims. But the editorial points out that other lawmakers disagree. Rep. Kevin Brady (R-Texas) said, “It’s frustrating that every lawyer in Washington has a wildly different opinion of which ‘version of legislation’ works best with our Texas law, but given the choice between who is looking out more for Texas, President Bush or some congressman from Iowa, I choose the President.” The editorial concludes, “It is just this complexity and difference of opinion that makes this such a difficult issue to resolve. … Just as the physicians’ code is to ‘do no harm’ to their patients, whatever emerges from the coming House-Senate battle in Washington should do no harm to Texas law and Texans’ rights” (Houston Chronicle, 8/6).

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