Review boards shown to favor HMOs in disputes

The Associated Press
Tuesday June 12, 2001

LOS ANGELES — Acting under a new consumer protection law, state regulators have sent nearly 200 disputes between HMOs and patients to an independent review board, which has ruled in favor of the health plans 65 percent of the time. 

A report – obtained by the Los Angeles Times but scheduled for release Monday by the California Department of Managed Health Care – is providing the first view of how recent HMO reforms have affected access to care and how consumer complaints are handled. 

Since the independent review law took effect Jan. 1, the department has sent 195 cases to be reviewed by outside doctors with no stake in the case’s outcome.  

The reviewers have rendered a decision in 168 of those cases: 110 have favored HMOs and 58 have gone to patients. The remainder are pending. 

Consumer advocates and state officials hope the report will aid Congress as it debates national patients’ rights legislation this week that contains some elements, such as expanded rights to sue HMOs, similar to California’s law. 

The health care industry has opposed patients’ rights legislation because it would enhance consumers’ rights to sue, which could lead to frivolous lawsuits and rising health care costs. 

“Certainly we have not seen that happen” in California, said Daniel Zingale, director of the managed care agency, which regulates HMOs.  

“And I would say that California’s laws are among the strongest in the nation” as far as protecting consumer rights. 

Consumers can sue HMOs if they are dissatisfied with the review process. But state officials and consumer advocates said they are unaware of any such lawsuits being filed since Jan. 1. 

The report also lists consumer complaints covering some 50 health plans. 

Among private plans with more than 1 million members, the plans with the lowest complaint rates were Aetna US Healthcare, with 0.67 complaints per 10,000 members, and Kaiser Foundation Health Plan, with 1.22 per 10,000. 

Among larger plans, the highest rate of complaints were registered by Health Net, with 2.3 per 10,000, and PacifiCare of California, with 2.52 per 10,000 members. 

Consumer advocates said it’s unclear what the scorecards mean without more data. 

The report, for example, listed zero complaints against LA Care, a manage care plan that serves nearly 2 million members in Los Angeles County.  

It was unknown how there could not be a single complaint lodged against the plan, Zingale said, but he speculated that frustrated patients may have lodged their complaints with another state agency.