In his acceptance speech last Thursday, Sen. John McCain (R-AZ) rallied against “government bureaucrats” injecting themselves into the patient-doctor consult, limiting care, and rationing treatments. But if McCain believes that bureaucrats are the third wheel in the confidential patient-doctor relationship, then the senator — who, as a beneficiary of government-run health care has probably never had to appeal a denied insurance claim to an HMO — may be surprised to learn that insurance company bureaucrats are already crashing the date.
A study of the independent medical review process (IMR) in California revealed that “among all areas of dispute, IMR upheld the original HMO decision at least half the time in most clinical areas and for most services, but nonetheless, fully one-third of HMO denials were overturned. “This suggests that the external IMR process adds some patient protection to California’s health care system,” the study concluded.
Currently, “41 states (plus the District of Columbia)” offer consumers the “option of an external appeal.” According to the Kaiser Family Foundation, “the insurers are overruled in about half of cases, with the rate of patient victory ranging from a high of 72% in Connecticut to a low of 21% in Arizona and Minnesota.”
Stories of HMO nightmares abound. After listening to McCain’s acceptance speech, Thomas Hayes wrote an open letter to the senator, reminding him that insurance companies often deny medical claims:
After struggling with many courses of treatment over the years, her Urologist has settled on a particularly effective medicine. But her insurance provider, Health Partners, decided that was too expensive, and since she was a woman of a certain age they determined that she could just as effectively be treated with another class of less-expensive drug.
They didn’t consult with her Urologist, mind you, they just decided she was obviously one of those middle-aged women who has bladder/incontinence issues, and that she’d have to change to another medical treatment. After all, they’d paid for 5 years of an effective course of therapy already, so it was time to try something cheaper. It didn’t work. So they proposed another drug. It didn’t work. They proposed a third alternative. You guessed it: no success.
It’s unclear if McCain’s health care proposal, which shreds consumer protections by allowing insurance companies to market national policies from states with minimal consumer protections, would undermine the internal and external review processes. Would insurance companies be able to move to one of the 9 states that do not have a mandatory review process and deny claims without ever being audited? McCain’s health care rhetoric suggests that they might:
I offer a genuinely conservative vision for health care reform, which preserves the most essential value of American lives — freedom…In health care, we believe in enhancing the freedom of individuals to receive necessary and desired care. We do not believe in coercion and the use of state power to mandate care, coverage or costs. [Des Moines, 10/11/2007]