J. Greene

       The shotgun marriage between patients and HMOs has been on the rocks for awhile now — they hardly talk anymore and trust each other even less. Maybe it’s time for a third party to step in and provide some counseling.
      Taking the worst knock-down, drag-out fights to outside medical experts is becoming an increasingly popular idea. Politicians in at least 18 states have turned to a process called external review as a balm for acrimonious disagreements over insurance coverage, especially in cases of expensive, high-tech and experimental treatments. Congress is also considering mandating this option across the country.
       A handful of health plans have been using external reviews for several years, mostly in cases where experimental treatments have been denied for dying patients. But some insurers and states have expanded their use so that people can seek an expert opinion in more everyday coverage spats.
      "This helps our members maintain a level of trust and confidence that if they just don't agree with the decision that HealthNet makes, there's someone independent of HealthNet reviewing it," says Ron Yukelson, spokesman for the California-based plan that has about 2.2 million members.
      Given all the well-publicized treatment denials these days, it would seem that expert panels would be working day and night to respond to a flood of requests. A majority of health-plan members report that they've personally had a problem with their HMO, and nearly a quarter of them say a dispute has heated up to the point where they wanted to file an appeal with an independent reviewer, according to a 1998 survey by the Kaiser Family Foundation.
       Surprisingly, relatively few disputes actually make it to external review, according to a study by the Institute for Heath Care Research and Policy at Georgetown University. In Michigan, which has had a review law in place since 1978, just 49 external reviews were conducted between 1995 and 1998 out of a total HMO enrollment of 1.8 million. And Medicare, which automatically refers cases to outside experts if a patient's appeal is rejected, sends out just two cases per 1,000 managed-care enrollees.
       If denials of care are so common and highly publicized, why so few reviews? State regulators suspect the low participation rates might be because of lack of awareness; consumers might be more likely to take advantage of an independent opinion on their case if they knew one was available. They also note that sick people are less able to pursue an extended battle with their health plans.
       "A lot of problems are going unresolved," argues Larry Levitt, who runs the Kaiser Family Foundation's research on the health-care system. "Many more people could be helped by these systems."
      It's also important to note that not all external-review programs are created equal. For instance, some outside reviewers aren't really independent, Levitt says — they may be doctors whose income depends on the health plan. “If a health plan is offering this voluntarily and is in charge of it,” he asks, “how independent can it really be?”
      States that have set up external-review requirements have tried to address the independence problem by requiring that all expert panel members be free of conflicts of interest in the case and disclose publicly any relationship they have with the health plan. In some programs, the reviewers are state employees.
      The usefulness of having a third party available can also be eroded if the types of complaints that can be heard are limited. Florida and Michigan, for instance, open the process up to any disagreement not resolved internally by the plan. In other places, review is limited to experimental therapies for people with terminal illness.
      In the places it's allowed, consumers seek a third opinion on a wide range of troubles. For instance, the Georgetown researchers found that Rhode Island consumers had the most problems getting inpatient services for mental health and substance abuse. In Texas, disputes over pain management and substance-abuse treatment were most common, followed by cancer cases. Other typical disputes involved the necessity of physical therapy after knee surgery, or weighing whether hormone therapy or hysterectomy was the best treatment in a given case.
      In many places, the outcomes of external review were about equally split between patients and HMOs. The Georgetown study found a range of 31 percent of cases decided for the consumer in the Medicare system, to 68 percent of consumers winning in Rhode Island.
       A few years into California HealthNet’s experiment with external review, about half the cases are found in favor of the consumer. But only about half the appeals even make it that far. A number of them are weeded out at the medical-group level when the health plan decides that the doctor's office made the wrong call. And in many other cases, the HMO and the patient negotiate an alternative treatment without having to turn to a third party.
      The HMO sees a consumer's appeal as an indication that something is wrong within its system, and looks closely at trends in the appeals for ways to improve. "We try to minimize the incidence of appeals," says HealthNet spokesman Yukelson. "Our absolute goal is to stop them altogether."
       The experts who help HMOs make the tough "gray zone" medical decisions hope the influence of reviewers will give health plans a chance to update or rewrite their coverage policies so they don't fight with their members as often. It can be especially helpful for smaller health plans that don't have staffs on hand to keep up on the latest technologies, and for individual doctors who are pressed to keep up as well. "The amount of material coming across their desks is just so massive," notes Lyon. Disputes may become less common as doctors have a better understanding of the latest research on a given treatment — known as evidence-based medicine.
      "When physicians know that the standard to be applied is evidence-based medicine, they stop requesting procedures that won't pass muster," Lyon says.
      Consumer advocates hope the trend won't derail efforts to establish a federal law that gives patients the right to sue their health plans. Still, the expansion of external review should help many health-plan members when they start feeling like throwing some crockery around. "There are more places to turn than many people realize," says researcher Levitt.

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