HMO Users’ ‘Bill of Rights’: Its Time Has Arrived

Managed care was pioneered in California, so it is no surprise that efforts to curb its excesses would start here. Since 1995, the state has seen a flurry of legislation aimed at establishing a “bill of rights” for HMO users. Only a few of the measures, most famously one that prevents “drive-by deliveries,” have become law. But now reform is going national, with bills before Congress that seek to weave a safety net of basic rights for HMO patients.

A presidential commission composed of health care executives and consumers and led by Health and Human Services Secretary Donna Shalala and Labor Secretary Alexis M. Herman began meeting seven months ago to analyze this legislation. Wednesday, the panel issued a sensible set of recommendations that uphold the most fundamental consumer rights but steer clear of micromanaging health care decisions. Congress should act swiftly to affirm three principles in particular:

* Payment should be guaranteed for emergency room visits if a “prudent layperson”--not an insurance company or HMO employee--would agree the visit was warranted.

* HMOs should disclose doctors’ experience in performing procedures and the bonuses and other incentives used to control costs. Physician experience can make a big difference, especially with surgery. But as it was put by one panel member, Oxford Health Plans Chairman Stephen F. Wiggins, “Most patients have no idea if they are the first person or the 50th person to have surgery performed by a particular physician.”

* Patients should have the right to an “external review” of decisions that deny payment for services and to appeal such decisions to an outside authority.

To comply with a state bill passed last year, HMOs in California are already establishing external review boards to which terminally ill patients can appeal when they are denied coverage for experimental medical treatments. But since HMOs themselves hire the “outside” panels, it remains to be seen whether those panels will act with full independence. Congress could require that review boards be assembled by a neutral party like state departments of health.

Managed care has been key to reining in the country’s health care costs, and Congress should not hastily pass bills that are excessive in determining health care decisions. But the rights spelled out by the presidential panel would help restore a sense of balance between patients’ needs and the dictates of medical gatekeepers.