Consumer complaints regarding the right to appeal a medical determination have put external review on the legislative map.
External review is an independent dispute resolution process that evaluates the appropriateness and necessity of medical treatments and determines whether insurers should allow alternative and experimental therapies. Often consumer complaints about health plan coverage can be resolved within a matter of weeks.
State legislators have addressed the issue in response to outcries from consumers and media reports that have painted managed-care plans as more interested in cutting costs than providing quality care. The National Conference of State Legislatures reported that as of October, 30 states and the District of Columbia require plans to establish an external review process for enrollees if the internal appeals process proves unsatisfactory.
The states' reviews vary greatly as to what types of appeals or claims can be filed, who performs the review and whether it is binding.
The proliferation of state laws notwithstanding, some plans have taken their own initiative: Aetna U.S. Healthcare voluntarily provides for review of coverage decisions for members in states that have not adopted external review legislation. The plan has contracted with four independent review organizations to handle the appeals. Since the beginning of 1999, 19 cases have reached external review, and seven have given the patients the treatment they requested.
"ER gives members confidence that we will not make a decision that can't be repealed," says Arthur Leibowitz, M.D., chief medical officer for Aetna in Philadelphia, "and offers the plan a chance to obtain information that may lead to policy changes. Although, that has not yet happened because most cases have been minor." Leibowitz says the plan puts its coverage policies on the Internet for its members, so "they can see the scientific basis for our decisions. It holds the plan up to scrutiny."
Leibowitz says the move to offer external review voluntarily was not a defense mechanism to prevent patients from suing. Since review decisions are not binding, patients could sue anyway.
He says Aetna offers external review to ensure its members receive the care they need and as an extra layer of security when it comes to medical decision-making.
Other insurers have turned to external review as well. New York City-based Empire Blue Cross and Blue Shield developed its mandatory ER for experimental and investigative cases in January 1997 and extended it to all denied claims the following year. New York enacted a review law last July pertaining to any adverse determination.
"When doctors know that recommendations will be reviewed by experts, it decreases frivolous cases," says Deborah Bohren, Empire's vice president of public affairs. Bohren agrees with Leibowitz that ER also gives plans timely informtion and quicker feedback for updating policies. For instance, after four cases regarding tandem transplants for multiple myeloma were upheld through ER, Empire decided to approve the procedure.
Although no organization tracks the number of cases nationwide, companies interviewed for this article indicated that only a few cases have gone as far as the external review process. And of those that have, most decisions have been split just about evenly between the patient and the plan, according to plan representatives.
"Even if ER is not being used that much, that doesn't negate its value," says Michael Hawkins, M.D., medical director of United HealthCare of Texas in Austin.
"It gives patients choice, the option to see someone independent. By having an external opinion, both the member and physician can feel that an unbiased independent decision has been made by an expert."
Eugene Ogrod, M.D., chief medical officer for Sutter Medical Foundation in Sacramento, Calif., concurs. "ER goes along way in giving patients trust in the healthcare process and in the plan. You can't underestimate that benefit," he says.
Paul Handel, M.D., a urologist at Texas Medical Center in Houston, says health plan enrollees are the winners because "half of patients get what they want, and the other half are spared unnecessary treatments."
In addition to advantages for patients, external review offers benefits for health plans and physicians. These include building credibility and facilitating more informed, educated decisions relying on evidence-based medicine.
"If a plan is consistently having its decisions overturned, it should look more carefully at the decision-making process," Hawkins says. "If they are not being overturned, ER confirms their decisions."
Physicians can take advantage of the same learning experience. Ogrod says that often the reviewer can provide physicians access to scientific literature they might not otherwise read and which can better explain how a decision was reached. Reviewers also are able to provide plans' medical directors, who may only be familiar with certain specialties, with leading-edge science to guide their future decisions in all areas of healthcare.
Jerry Reeves, M.D., senior vice president/chief medical officer for Louisville, Ky.-based Humana, says he believes that when attending physicians and reviewers share the same body of reputable information, they are likely to reach the same decision. "The problems set in when the information doesn't jibe with requests for new techniques or quality-of-life drugs which may have marginal benefits and high costs," he says.
Although external review may validate physician decisions, doctors may find themselves caught between patients and plans, trying to do what's best for the patient while convincing the plan of the appropriateness of a treatment. This could potentially cause a shift in doctor-patient and doctor-plan relationships.
Empire's Bohren believes ER can increase trust between the physician and health plan because a third party is making the decision, taking the onus off the plan and giving the do-ctor a level of comfort.
Randolph Smoak, M.D., president-elect of the American Medical Association and a surgeon in Orangeburg, S.C., agrees that ER has the potential to improve the doctor-patient relationship. "It helps relieve stress between them because the doctor is no longer responsible for explaining to a patient why a treatment was denied," he says. "The plan becomes the bad guy."
But Donald Logan, M.D., chief medical officer for the Dean Clinic, part of Dean Health Systems in Milwaukee, says he believes that ER can be adversarial for all parties involved.
"Most grievances are the result of misunderstandings; there are really just a small number of controversial subjects," he says. "It comes down to treatments with little value, which shouldn't be approved, or doctors who should not have offered an uncovered benefit." Doctors who believe strongly that a treatment is valid should document that to the plan early on, he says.
Little uniformity exists among the state laws governing what types of appeals or claims are eligible for external review. Denials may apply to any covered service, an adverse utilization review decision, an adverse determination related only to medical necessity and appeals only for experimental or investigational therapies. Many of the laws enable any HMO member or provider acting on the member's behalf to initiate a review, grant the state insurance commissioner the role of selecting an independent review panel or authorizing independent review organizations and determine who is responsible for carrying out the decision.
What often becomes confusing, however, is distinguishing between what is medically appropriate and what is a covered benefit.
When coverage for treatment is not specifically spelled out in a contract, medical necessity is the determining factor. Peter Goldschmidt, M.D., president of Medical Care Management in Bethesda, Md., an organization promoting informed medical decisions, says plans are interpreting what's recommended based on inclusions in a contract instead of trying to second-guess physicians. He worries that plans may be approving too much and paying for what may be inappropriate.
Minneapolis-based UnitedHealth Group's decision to grant its physicians the final say on most treatments for their patients may greatly diminish the need for ER, especially if other health plans follow suit. "The potential uses will be when ER applies to determinations on experimental, investigational and cosmetic treatments," Hawkins says.
Perhaps the biggest unanswered question is whether more outside review will decrease the number of lawsuits against health plans. Reeves is not sure, but he says he is certain the best route to quality is not through the courtroom. "The benefit of ER is that it takes place in real time when it can be beneficial to the patient, not three years after the fact," he says.
Mari Edlin is a Mill Valley, Calif.-based business writer.