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A large study was recently concluded examining what happens when patients appeal the decisions of HMOs. The study, according to Reuters news service, looked at over 1700 appeals – as handled through the HMO’s internal appeals process – brought by patients enrolled in 2 large California health plans between 1998 and mid-2000. As with most such studies, the meaning of the results depends on who is looking at them. |
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Contrary to what one might predict, only a minority of cases (37%) had to do with disputes over “medical necessity” – a question of whether a denied service or procedure was actually needed. Of these, slightly more than half were ultimately decided in favor of the patients. Of the “medical necessity” appeals that went in favor of the HMOs, 12% had to do with the treatment of scars or other benign lumps or bumps, and another 20% were related to denial of certain diagnostic tests. The majority of the appeals actually had nothing to do with medical necessity disputes, but instead were related either to whether a service or procedure was covered by the health care contract, or to whether a patient could get covered services outside the HMO's designated network. HMOs won the majority of these kinds of appeals. The authors of the study, according to Reuters, expressed some surprise that “medical necessity” questions were relatively infrequent, and that the appeals that were brought often did not involve particularly “grave concerns.” Similarly, the president of the American Association of Health Plans (think of it as the AMA for HMOs) asserted that the study “confirms that health plans are helping patients get the care they need, when they need it.” DrRich Comments: The beauty of studies like this is that they allow us to draw almost whatever conclusions we would like. If we’re apologists for HMOs, the study shows that HMOs really aren’t that bad. Patients didn’t seem to have had that many complaints in the first place (given that millions of patients were enrolled in these two plans), and the complaints they had tended to be relatively minor. And furthermore, patients who did complain ended up getting what they wanted a majority of the time, at least for “medical necessity” complaints. Therefore, the internal appeals processes set up by HMOs work just fine, and there is no need to establish an external appeals process at all – especially not one mandated by federal law. On the other hand, if we’re inclined to think the worst of HMOs, this study doesn’t really tell us anything about unreasonable denials of care. We have no idea from this study, for instance, how often the more grievous “medical necessity” denials might actually occur, or what happens to patients who are affected by them. Perhaps such denials truly are rare. Or perhaps a lengthy, legalistic appeals process is simply not a feasible means of addressing the needs of patients with acute or life-threatening conditions – so patients with this kind of grievance “select themselves out” of the internal appeals channel. And even if the particular appeals processes run by the two HMOs included in this study work as well as the data might suggest, every HMO handles appeals differently – the results might be quite different if they had been measured in the HMO down the street. But more importantly, the results as reported in this study, even if accepted at face value, should not give anyone much comfort. To make the data come out favorably, all an HMO has to do is to deny dermabrasion therapy for 3 patients with scars for every patient who is denied needed heart bypass surgery. This way, a large majority of “medical necessity” denials are relatively “trivial,” and not worth working ourselves up into a lather about, just like the data says. As long as you deny enough "minor complaints," the impact of denying occasional major grievances will be buried within the statistics. March, 2003 YourDoctorintheFamily.com Home Page
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