Friday, June 04, 1999
'Patient Protection' bill loses liability provision
BY MICHAEL HAWTHORNE
Enquirer Columbus Bureau
COLUMBUS — Responding to complaints that health insurance companies are more interested in profits than patients, the House approved legislation Thursday allowing Ohioans to appeal denials of coverage to independent experts.
While the measure sailed to passage, the 82-14 vote didn't reflect the emotional debate over an unsuccessful attempt by Democrats and a handful of Republicans to give Ohioans the power to sue health insurers if they are denied treatments.
Supporters of the amendment said they were seeking to fulfill one of the campaign promises made by Republican Gov. Bob Taft, who vowed to make insurers liable for their decisions.
But Republican leaders, acting at the behest of influential insurance and business interests, stripped out the liability provision in Mr. Taft's bill. They contended it would drive up the cost of health care and force employers to cut benefits.
HOW IT WORKS
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Legislation adopted by the Ohio House on Thursday sets forth how a person enrolled in a health plan can appeal denial of insurance coverage. Here's a step-by-step process:
• If the health insurer denies coverage for a particular procedure, the enrollee appeals to the company.
• The insurer reviews the appeal according to an internal plan approved by the state superintendent of insurance.
• If the denial is based on grounds that the service requested is not covered by the enrollee's policy, an appeal can be made to the insurance superintendent.
• If the denial is based on grounds that the service is not medically necessary, an external review is conducted by an independent review organization assigned by the superintendent.
• The review group must use medical experts and clinical peers who have expertise in the treatment of the enrollee's medical condition. The decision is binding.
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The bill now heads to the Senate, where the Republican majority appears to have the votes to send it to Mr. Taft. The new governor has said he
will sign the measure even if it doesn't include the liability provision.
Rep. Dale Van Vyven, R-Sharonville, said the appeal process established in the bill would ensure patients get answers more quickly than they would by suing their insurers.
“We're not just talking about things that look good on paper. We're talking about real accountability,” said Mr. Van Vyven, chairman of the House Health, Retirement and Aging Committee. “Who would you trust to make these decisions? Independent medical experts or 12 people (on a jury) who know nothing about health care?”
The self-described “poster child” for reforming Ohio's health care system doubts the new system will work as well as its proponents claim.
Linda Smrdel Kerns spent $150,000 for a bone marrow transplant while fighting her insurance company's refusal to pay for the procedure her physician recommended. Without the treatment, the Columbus woman said, she would have died from breast cancer, the same disease that killed her mother, sister, aunt and great-grandmother.
Ms. Kerns fought her insurance company for 11 months before it agreed to pay for the procedure.
Democratic gubernatorial candidate Lee Fisher repeatedly mentioned her case on the campaign trail last fall as he promoted his health-care reform plan. Mr. Taft also took up her cause when he followed Mr. Fisher with a similar plan to give patients the right to sue their health maintenance organizations (HMOs).
Echoing lawmakers who backed the liability provision in the House, Ms. Kerns contends the fear of being sued would make HMOs more likely to pay for early, more affordable care.
“Nobody seems to be listening to the patients now that the (election) campaign is over,” she said. “My insurer had an appeals process, too. But I had to hammer and hammer and hammer at them before I got the treatment I needed.”
Under the bill sent to the Senate, patients who have been denied coverage would first appeal to their HMO. If they aren't satisfied, they could ask the state Department of Insurance to determine whether the recommended treatment is covered under their insurance plan.
Disputes over the medical necessity of treatments would be sent to randomly selected panels of medical experts, certified by the Insurance Department, that would review the cases and make binding determinations about whether the procedures should be covered.
Life-threatening cases would be decided within seven days and all others within 30 days. The bill also requires the reviewers to have clinical experience within the previous three years with the treatment in question.
“We are making health care in this state much better,” said Rep. Randy Gardner, R-Bowling Green, the measure's chief sponsor. “The people of this state can have more confidence that health care decisions are made more promptly and wisely.”
Mr. Taft noted the measure also would allow women to see their obstetrician or gynecologist without a referral and authorizes new tax breaks for medical expenses.
Most of the debate focused on an amendment offered by Rep. Jeff Jacobson, R-Brookville, that would have allowed patients to sue if a coverage decision or unreasonable delay harmed them.
It failed on a 53-45 vote, with seven Republicans joining 38 Republicans in favor. Rep. Jerry Luebbers of Cincinnati was the lone Democrat to vote against the amendment.
If doctors can be sued when they make bad decisions, Mr. Jacobson said, so should health insurance companies.
Rep. Betty Sutton, D-Barberton, accused fellow lawmakers of allowing insurance and business interests, two of the top sources of Republican campaign contributions, to shape the bill. She noted Mr. Van Vyven once said insurance lobbyists wouldn't discuss the bill unless the liability provision was removed.
“Instead of putting those lobbyists in their place, we put them in our place,” Ms. Sutton said. “We are being called upon to rise above the campaign contributions and look out beyond the lobbyists to see our constituents.”
Along with Rep. Sam Britton, D-Cincinnati, she was one of the 12 Democrats and two Republicans to oppose the overall bill.
In recent weeks, supporters of the liability provision lost one of their key supporters: the Ohio State Medical Association. Changes made by the House will still ensure patients receive prompt medical care, said Tim Maglione, the association's chief lobbyist.
“We wanted more accountability, and that's what we're getting with this bill,” Mr. Maglione said.
Insurance companies and business groups, meanwhile, argued that court decisions already are opening the door to HMO lawsuits. But they pulled out the stops to prevent the House from adding specific liability language to the bill.
For instance, the Ohio Chamber of Commerce financed campaign-style radio ads intended to drum up opposition to Mr. Jacobson's amendment. “Call Rep. Jacobson. Tell him to lose the sue-everybody amendment so you don't lose your health care,” the ad said.
“We had a process that didn't represent the people,” Mr. Jacobson countered. “No matter how well-intentioned people were, the lobbyists for the health insurance industry controlled the outcome.”
Ohio will join 39 states that have enacted similar patient-protection bills in the past five years.
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