Letters to the Editor

If Patient Protections May be Unlawful, It's Time to Change the Law

January 18, 2002

The Rush Prudential v. Moran case [HMO Seeks Overturn of Illinois Law, January 17, 2002] clearly demonstrates that health maintenance organizations (HMOs) are opposed to any laws holding them accountable for their medical decisions, either on the state or federal level.

The HMO industry argues that it opposes a patients' bill of rights because of concerns about lawsuits. The real issue, however, is whether HMOs must answer to anyone besides their own hired reviewers when they deny care that a patient and the patient's physician consider necessary. Lawsuits are best avoided by giving both the HMO and aggrieved patients the right to access an independent medical reviewer when there is a dispute.

In the Illinois case, a Supreme Court finding in the HMO's favor would invalidate state laws nationwide that are holding managed care companies accountable for medical decisions. This would set the clock back to a time when insurance companies could arbitrarily deny care without fear of any negative repercussions.

The American College of Physicians - American Society of Internal Medicine believes that HMOs must be held accountable for their medical decisions. Independent external review by qualified doctors of an HMO's denial of medical care should be available to all. Patients who have been harmed by a denial of care should be able to have their case heard in court, but only as a last resort. State legislatures are doing their best to assure these rights-but it takes an act of Congress to make these rights the law of the land.

The Illinois case shows the urgent need for Congress to pass a PBR law - without delay -- that the President would sign. Otherwise, the HMOs will continue trying to use lawsuits and every method at their disposal to return to the days when they could arbitrarily deny needed medical care, without having to answer to anyone.

Dr. William J. Hall, FACP
President
American College of Physicians- American Society of Internal Medicine
PO Box MED
University of Rochester
601 Elmwood Avenue
Rochester, NY 14642
Office (716) 275-4310
Cell (716) 750- 1637
william_hall@urmc.rochester.edu

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