Curbing the power of HMOs Medical decisions: Bills seek better balance among HMOs, physicians and patients.

March 20, 1997

A BILL that would require health insurers to give patients the right to appeal unfavorable decisions on coverage would not entirely correct the imbalance of power that characterizes many of these situations. But it would be an important step in the right direction, and we urge its passage -- provided that insurers bear some of the costs.

Health insurers, especially health maintenance organizations and other managed care groups, have profited handsomely on their ability to control spiraling costs for medical care. But the trade-off has become painfully clear: In too many cases, medical decisions are made not by physicians in the best interests of the patient, but by bean-counters more concerned with the insurer's bottom line.

As a result, legislators face increasing pressure from voters outraged by situations ranging from outpatient mastectomies and drive-through deliveries to arbitrary decisions not to pay for chemotherapy or radiation before cancer surgery, rather than afterward -- despite research showing that, in certain circumstances, reversing the traditional order of those treatments can produce better outcomes.

No wonder that health care bills have proliferated in Annapolis, and that many are aimed at curbing the power of managed-care companies. One important bill, now stalled on the floor of the Senate, would bring medical directors of HMOs under the authority of the state Board of Physician Quality Assurance. These physicians don't treat patients, but they decide what kind of care other doctors can give. They ought to be accountable for those decisions.

HMOs have now signed onto legislation that would allow patients to appeal decisions in which they are denied coverage for specific procedures. The appeals process would involve the state attorney general's office and the insurance commissioner. That is an improvement over the current state of affairs, which allows for no outside appeals, but the process is nevertheless cumbersome for patients and would require additional resources for these state offices to take on this responsibility.

Insurers ought to shoulder some of this expense. And this measure should be only a first step in a thorough policy review by the General Assembly aimed at achieving a better balance of power in decisions about health care.

Pub Date: 3/20/97.

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