WASHINGTON – A heavily divided Supreme Court ruled Thursday that states can help patients fight their HMOs, a decision that could increase requests for second opinions.
The court voted 5-4 to endorse an effort, like those used in about 40 states, to let patients bypass health plan gatekeepers who refuse to approve payment for a treatment. The ruling also lifts pressure off Congress, which has failed to pass a national patients' rights plan.
The state laws are intended to let people get second opinions, and sometimes force health maintenance organizations to pay up if an independent review shows a surgery or other care is justified.
The Supreme Court said that states, in trying to better arm patients in their battles with big HMOs, did not conflict with a federal law.
The ruling comes months after patients rights legislation stalled at the Capitol after the Sept. 11 attacks, putting on hold plans for a nationwide system for independent evaluations. The subject has been part of closed door talks this year, with no consensus.
HMOs had argued that they were not opposed to independent review boards, but wanted one national standard instead of the hodgepodge of state laws.
The Supreme Court upheld the Illinois procedure used by Debra Moran to get her health plan to pay for an operation that fixed her rare, debilitating nerve problem. The surgery cost about $95,000.
The decision focused on whether a 1974 federal law governing most employee benefit plans overrules the state laws on independent reviews.
The court determined it did not, ruling against Moran's health carrier, Rush Prudential HMO Inc., which has been purchased by Wellpoint Health Network.
Justice David H. Souter, writing for the majority, said the law says nothing about second opinions, and that the state law was allowed.
The 1974 law has bedeviled the Supreme Court over the years, prompting multiple rulings on how far states can go to set their own rules for employee benefits. The rulings have provided no clear guidelines for how states can impose their own regulations.
Thursday's decision affirms a ruling by the 7th U.S. Circuit Court of Appeals in Chicago, which said under Illinois law, Moran was entitled to both the review and the reimbursement.
Independent reviews are not frequently sought. In 2000, about 2,500 cases were accepted for full review in 16 states surveyed by the American Association of Health Plans. The reviewer upheld the decision made by the insurers' doctors in about half of those.
Health care advocates contend one reason for the low numbers is that people are unaware of the option. That could change with the attention from this case filed by Moran, a speech therapist.
Moran's health problems began in 1995. Physical therapy and other treatments recommended by her primary care doctor did not relieve her arm pain, so she sought the opinion of a surgeon who did not participate in her health plan. That doctor recommended a more extensive surgery, which Rush Prudential refused to pay for. Two specialists also said she did not need the extensive surgery.
Moran, who lives in suburban Chicago, demanded a separate review and an outside expert agreed that the surgery was necessary.
The case is Rush Prudential HMO v. Moran, 00-1021.
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