Few Patients File External Appeals Under New Massachusetts Patients’ Rights Law

Although a new Massachusetts patients' rights law allows patients to ask an independent board of doctors to "overrule" denials of medical care by health plans, few patients have filed appeals since the law took effect in the state, the Boston Globe reports. A review of the 31 external appeals filed under the law, which took effect Jan. 1, found that 30 involved "non-critical treatments," including 10 plastic surgery cases, four physical therapy cases, two speech therapy cases and two prescription drug cases. The review board ruled in favor of patients in seven of the cases and "upheld" health plan decisions in 24 cases, according to state documents. In addition, the state Office of Patient Protection, which administers the appeals process, rejected 14 cases that "did not involve medical issues" and "stepped in to correct" an "obvious error" by a health plan in six cases. Nancy Ridley, assistant commissioner of the state Department of Public Health, said, "The caseload is probably not as high as we initially thought it would be." Under the Massachusetts patients' rights law, patients must exhaust internal appeals within health plans before filing an external appeal, which costs $25 (Mishra, Boston Globe, 8/26). Insurers have 30 days after receiving a patient's complaint to conduct an internal review, and patients have 45 days after the insurer issues an internal review decision to request an external review. The law does not cover Medicare or Medicaid beneficiaries or self-insured patients (Kaiser Daily Health Policy Report, 1/4).

'Unfounded' Criticism?
According to state health plans, the results in Massachusetts "indicate" that the "hue and cry against HMOs, now a staple of politics, is unfounded," the Globe reports. However, HMO reform advocates said that most patients "are simply unaware of their rights" under the new law and "flatly reject" that patients have "widespread satisfaction" with health plans. "There's a whole lot of things in life that people like to (complain) about. But when there is a critical mass of HMO complaints to every legislator, you can be sure there is a fire behind the smoke," state Sen. Mark Montigny (D), who drafted the Massachusetts patients' rights law, said. However, a study conducted by the American Association of Health Plans found that in the United States, only one in 14,000 members files an appeal against their health plan each year. The Globe reports that in Massachusetts, an "even more lethargic" one member per 53,000 will file an appeal this year. Still, some cited the study as "evidence the review process is actually working." Joan Alker, associate director of government affairs for Families USA, said, "The fact that there are low numbers can mean that the external review process is acting as a deterrent to bad behavior" (Boston Globe, 8/26). For further information on state health policy in Massachusetts, visit State Health Facts Online.