External Reviews the Answer?
The shotgun marriage between patients and HMOs has
been on the rocks for awhile now they hardly talk anymore and trust each other even
less. Maybe its time for a third party to step in and provide some counseling.
Taking the worst knock-down, drag-out fights to outside medical
experts is becoming an increasingly popular idea. Politicians in at least 18 states have
turned to a process called external review as a balm for acrimonious disagreements over
insurance coverage, especially in cases of expensive, high-tech and experimental
treatments. Congress is also considering mandating this option across the country.
A handful of health plans have been using external
reviews for several years, mostly in cases where experimental treatments have been denied
for dying patients. But some insurers and states have expanded their use so that people
can seek an expert opinion in more everyday coverage spats.
"This helps our members maintain a level of trust
and confidence that if they just don't agree with the decision that HealthNet makes,
there's someone independent of HealthNet reviewing it," says Ron Yukelson, spokesman
for the California-based plan that has about 2.2 million members.
Given all the well-publicized treatment denials these
days, it would seem that expert panels would be working day and night to respond to a
flood of requests. A majority of health-plan members report that they've personally had a
problem with their HMO, and nearly a quarter of them say a dispute has heated up to the
point where they wanted to file an appeal with an independent reviewer, according to a
1998 survey by the Kaiser Family Foundation.
relatively few disputes actually make it to external review, according to a study by the Institute for Heath Care Research and
Policy at Georgetown University. In Michigan, which has had a review law in place since
1978, just 49 external reviews were conducted between 1995 and 1998 out of a total HMO
enrollment of 1.8 million. And Medicare, which automatically refers cases to outside
experts if a patient's appeal is rejected, sends out just two cases per 1,000 managed-care
If denials of care are so common and highly
publicized, why so few reviews? State regulators suspect the low participation rates might
be because of lack of awareness; consumers might be more likely to take advantage of an
independent opinion on their case if they knew one was available. They also note that sick
people are less able to pursue an extended battle with their health plans.
"A lot of problems are going unresolved,"
argues Larry Levitt, who runs the Kaiser Family Foundation's research on the health-care
system. "Many more people could be helped by these systems."
It's also important to note that not all
external-review programs are created equal. For instance, some outside reviewers aren't
really independent, Levitt says they may be doctors whose income depends on the
health plan. If a health
plan is offering this voluntarily and is in charge of it, he asks, how
independent can it really be?
States that have set up external-review requirements
have tried to address the independence problem by requiring that all expert panel members
be free of conflicts of interest in the case and disclose publicly any relationship they
have with the health plan. In some programs, the reviewers are state employees.
The usefulness of having a third party available can
also be eroded if the types of complaints that can be heard are limited. Florida and
Michigan, for instance, open the process up to any disagreement not resolved internally by
the plan. In other places, review is limited to experimental therapies for people with
In the places it's allowed, consumers seek a third
opinion on a wide range of troubles. For instance, the Georgetown researchers found that
Rhode Island consumers had the most problems getting inpatient services for mental health
and substance abuse. In Texas, disputes over pain management and substance-abuse treatment
were most common, followed by cancer cases. Other typical disputes involved the necessity
of physical therapy after knee surgery, or weighing whether hormone therapy or
hysterectomy was the best treatment in a given case.
In many places, the outcomes of external review were
about equally split between patients and HMOs. The Georgetown study found a range of 31
percent of cases decided for the consumer in the Medicare system, to 68 percent of
consumers winning in Rhode Island.
few years into California HealthNets experiment with external review, about half the
cases are found in favor of the consumer. But only about half the appeals even make it
that far. A number of them are weeded
out at the medical-group level when the health plan decides that the doctor's office made
the wrong call. And in many other cases, the HMO and the patient negotiate an alternative
treatment without having to turn to a third party.
The HMO sees a consumer's appeal as an indication that
something is wrong within its system, and looks closely at trends in the appeals for ways
to improve. "We try to minimize the incidence of appeals," says HealthNet
spokesman Yukelson. "Our absolute goal is to stop them altogether."
The experts who help HMOs make the tough "gray
zone" medical decisions hope the influence of reviewers will give health plans a
chance to update or rewrite their coverage policies so they don't fight with their members
as often. It can be especially helpful for smaller health plans that don't have staffs on
hand to keep up on the latest technologies, and for individual doctors who are pressed to
keep up as well. "The amount of material coming across their desks is just so
massive," notes Lyon. Disputes may become less common as doctors have a better
understanding of the latest research on a given treatment known as evidence-based
"When physicians know that the standard to be
applied is evidence-based medicine, they stop requesting procedures that won't pass
muster," Lyon says.
Consumer advocates hope the trend won't derail efforts
to establish a federal law that gives patients the right to sue their health plans. Still,
the expansion of external review should help many health-plan members when they start
feeling like throwing some crockery around. "There are more places to turn than many
people realize," says researcher Levitt.
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