Injecting common sense into patient-rights debate
|
The right to sue sounds good, don't you think? The trouble is that going to court is very expensive and often slow. A better solution is to establish a new independent, expert and rapid appeals process that is clearly beyond the health plan's control. Here is how such a system should work:
• The first step is to use the health plan's own internal appeals processes that are already required by law. Often, this works and the patient is satisfied.
• If a health plan doesn't act swiftly or responds negatively to this internal appeal, the patient or family should have the right to an independent expert review. Where delay could be harmful to the patient, completion of this independent expert review should be required within 72 hours.
• The independent review panel should be comprised of medical experts who practice in the specialty field for the care that's being questioned. This independent expert review should reflect the latest available medical knowledge and technology and be based on the "best practices" for the care in question. To help assure consistency across the country, a federal research and standards organization should be established to provide guidance (similar to the FDA for drugs). After all, patients diagnosed with cancer in Boise or Boston should be able to have the identical expectation for receiving the same quality care as someone here in Seattle.
• In order for decisions of the independent expert review panel to be effective, they must be binding on the health plan. If the health plan agrees to implement the independent review, no further action is necessary. But if the health plan does not follow the recommendation of this independent review, the patient then - and only then - should have the right to sue the health plan.
• If there is still an unresolved dispute, that dispute should be settled in federal court. This is because right now the standards a judge or jury uses to determine what constitutes "proper care" vary widely across the state court systems. Common sense says that both patients and their health plans should be able to rely on a common expectation for what constitutes proper care when a decision is made by independent expert review or if a dispute about that independent review decision ends up in court.
So what happens if Congress instead adopts a program in which health plans are subject to unlimited lawsuits, rather than the simple, common-sense approach outlined here?
First, health plans will have to raise their prices dramatically to cover significantly increased costs of litigation. This just happened in Arizona, where a new state law allows health plans to be sued with few limitations. Prices there immediately went up by 6 percent to 10 percent and even more. And this is on top of other large cost increases to cover new prescription drugs and other increased costs of care.
Second, smaller health plans will be forced to consider leaving the health-insurance business because of the unpredictable financial exposure from unlimited lawsuits.
And third, health plans may well end up approving medically unnecessary and sometimes dangerous, unproven experimental procedures simply in order to avoid lawsuits. This will have the effect of increasing costs for everyone who buys health insurance. It will also tend to lower the quality of care that health plans will pay for - a development no one wants.
Common sense says that consumers can best be protected from inappropriate denials of care through a system of independent expert review that is binding on health plans. And three out of four doctors agree that independent expert review makes more sense than lawsuits, according to a new national survey. It is through this kind of approach that patients' rights can be well and quickly protected, rather than relying on the slow, cumbersome and expensive process of litigation.
Ask yourself two simple questions about how you would want to challenge a health-plan decision on behalf of your loved ones: Would you rather get a quick, independent expert decision that is both binding on the health plan and based on the latest national research and best practices? Or would you rather trust your loved one's care to lawyers, courts and the unpredictable process of litigation?
When you reach a decision, write or call your own member of Congress ( www.house.gov or www.senate.gov ) and urge him or her to support a "Patients' Bill of Rights" that implements a program that is both effective and efficient.
Gary R. Gannaway is president & CEO of First Choice Health Plan. First Choice is owned by Washington hospitals and physicians and is committed to the goal of offering quality health care at a competitive price.