HMOs: Follow-Through Counts

Managed care’s critics point, one and all, to the lack of a credible appeals process for patients who feel treated unfairly. Without it, there is no counterweight to the impression that many HMOs are controlled by heartless bean counters. Finally, with legislators breathing down their backs, managed care organizations are tackling the problem.

Walter Zelman, a former Harvard professor who worked on the Clinton administration’s failed 1993 health care initiative, is point man on the issue for the California Assn. of HMOs, a trade group. This week he announced a plan for medical review panels to which patients could appeal when their HMOs denied care their doctors had recommended. The proposal is terribly vague, but if Zelman succeeds he could demonstrate that HMOs in the free market can resolve a problem that has so far eluded California legislators. A lot of details yet to be worked out will determine whether the plan is public relations or real consumer protection.

A credible plan would guarantee:

* Speedy appeals. The HMOs say consumers must exhaust existing internal appeals processes before going outside; that could take months. The system should resemble the one enacted by the Texas Legislature last year that resolves routine disputes within an average of 18 days and emergency ones within an average of nine days.

* Independent funding. Zelman’s proposal would allow HMOs to hire their own independent reviewers--making those reviewers, of course, anything but independent. The state, not HMOs, should select medical referees; a bill is in the works to do just that.

* Uniform methods of appeal. The plan would also allow each HMO to define its own appeals processes. The inconsistency and likely conflict are mind-boggling. A consistent industrywide review process would help HMOs as well as consumers, because it would help identify standards for which kinds of care are to be deemed medically necessary.

Some HMOs may opt out of the Zelman plan. For instance, officials at Kaiser Permanente, noting that legislators are working on external-review legislation, say they will hold off and see what lawmakers do. That would be a mistake. HMOs may not be able to stave off legislation by setting up their own independent appeals process, but they can influence that legislation and even help determine in advance what works and what doesn’t.