What if Michigan set up external review and virtually no one took advantage of i
What if Michigan set up external review and virtually no one took advantage of it?
Consumers unaware of appeal process, says legislator
In 1978, Michigan became the first state in the nation to set up an external review process for managed care decisions. But is it working?
In a state with more than 2.9 million people enrolled in managed care plans, the Michigan Department of Health’s HMO Task Force received only 63 grievances from 1995 through 1998. Of those cases, 12 were resolved before the hearing, and 41 had an airing before the task force. The task force upheld HMO decisions in 28 cases and found in the member’s favor in 13 cases. Ten cases remain pending.
It could be argued that Michigan’s HMOs are making few bad decisions. Or perhaps, as Rep. Laura Baird (D-East Lansing) asserts, most HMO enrollees are unaware that an external appeals mechanism exists. Subscribers may believe that, as the name implies, their plan is committed to maintaining health, she says, and "may take a refusal by an HMO to be tantamount to a medical opinion that they don’t need that treatment or care."
Ms. Baird has introduced HB 4127, which would extend civil liability to HMOs. Under current Michigan law, HMOs may be sued only for the value of the service or treatment not provided. She complains that subscribers "can’t recover the cost of the harm that occurred as a result of the HMO’s interjecting itself into medical decision-making," but is the first to acknowledge that her bill likely won’t be given a hearing in a Republican-controlled legislature.
Ms. Baird says she welcomes the National Committee on Quality Assurance’s external review initiative, but adds that it doesn’t remove the need for her civil liability bill. "People still need some muscle in their disagreements with their HMOs."
Contact Ms. Baird at (517) 373-1786 and Janet Olszewski of the Michigan Department of Community Health at (517) 335-5182.
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