Doctors applaud Supreme Court's HMO review ruling

Decision sparks renewed debate on stalled patients' bill of rights legislation.

By Tanya Albert, AMNews staff. July 8/15, 2002.

A recent U.S. Supreme Court ruling has helped physicians regain some control over medical decision-making that they felt slipping away to managed care companies over the past two decades.

In a 5-4 decision, the high court in June upheld an Illinois law that established an independent medical review system for cases in which a treating physician and a patient's health plan disagree on what is medically necessary for the patient.

Under the Illinois law, the health plan must pay for the treatment in question if the independent medical reviewer decides in a patient's favor.

The decision bolsters the physician-patient relationship in another 41 states and the District of Columbia, where similar state laws allow for independent review.

"It is a major victory for America's patients and their physicians," said American Medical Association President-elect Donald J. Palmisano, MD.

"Your medical judgment can't be so readily overridden by the HMOs," added Leonard Nelson of the AMA/State Medical Societies Litigation Center, which was part of a friend-of-the court brief. "Ultimately, the primary care physician isn't the last word, but at least they can take it one step further to an independent review."

The decision also will return some confidence to patients whose primary care physicians tell them a particular treatment is medically necessary while a physician from their health plan tells them it is not, said Mark Rust, an attorney for the patient.

"All physicians were concerned that there be an objective process in place when those opposing medical opinions sometimes occur," said Rust, managing partner of Barnes & Thornburg's Chicago office and chair of its health care department. [...]