- The Washington Times - Friday, June 21, 2002

A divided Supreme Court ruled yesterday that states can help patients fight their health maintenance organizations, a decision that could increase requests for second opinions.
The court voted 5-4 to endorse an effort, like those used in 42 states, to let patients bypass health-plan gatekeepers who refuse to approve payment for a treatment. The ruling lifts some pressure off Congress, which has failed to pass a national patients' rights plan.
The state laws are intended to let people ask for second opinions and sometimes force HMOs to pay 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 on Capitol Hill after the September terrorist 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 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 state laws on independent reviews.
The court determined it did not, ruling against Miss Moran's health carrier, Rush Prudential HMO Inc., which has been bought by Wellpoint Health Network.
Justice David H. Souter, writing for the majority, said the federal law says nothing about second opinions and that the state law was allowed.
In Winfield, Ill., a suburb of Chicago, Miss Moran said she hopes the decision encourages other patients to seek second opinions and independent reviews.
"They need to know the laws are out there," she said.
She said she knew the decision would be close, but the outcome "really shows that if you're adamant about your position, the justice system works for you."
"The champagne's been in the refrigerator a long time," said Miss Moran, who filed a lawsuit in 1998.
Justice Clarence Thomas said in a dissent that the ruling "undermines the ability of HMOs to control costs, which, in turn, undermines the ability of employers to provide health care coverage for employees." Justice Thomas was joined by Chief Justice William H. Rehnquist and Justices Antonin Scalia and Anthony M. Kennedy.
The 1974 employee-benefits law has bedeviled the Supreme Court over the years, prompting multiple rulings on how far states can go to set their own rules. The rulings have provided no clear guidelines for how states can impose their own rules.
Yesterday's decision affirms a ruling by the 7th U.S. Circuit Court of Appeals in Chicago, which said under Illinois law, Miss Moran was entitled to both the review and the reimbursement.
The decision potentially affects more than 70 million Americans whose employers buy coverage from a health insurance company, said Ron Pollack, president of Families USA, a liberal group that has been lobbying for a federal patients' rights bill. It does not help about 60 million people whose employers use self-insured plans.
Employers and insurance companies, who have been fighting the federal legislation, said the decision would increase the cost of coverage.
"By forcing employers and health plans to adhere to potentially 50 different conflicting state external review requirements, the court has dealt them a blow in the battle to control the already soaring cost of health care for working families," said a statement from the Health Benefits Coalition, a group of businesses.

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