By Gina Holland ~ The Associated Press
WASHINGTON -- A divided Supreme Court ruled Thursday that patients in 42 states can demand an unbiased second opinion when their HMO says no to a surgery or treatment.
The court's 5-4 decision was hailed by some as a safety net at a time when Congress remains gridlocked on a patients' rights bill. Others said it only illustrated the need for a national standard.
Justices upheld an Illinois law, like those in the other states, which allows patients to bypass health plan gatekeepers who refuse to pay for procedures.
The ruling could potentially help close to 70 million Americans whose employers buy coverage from health insurance companies.
The Supreme Court said that states, in trying to better arm those patients in their battles with big managed-care companies, did not contradict a confusing federal law.
The case highlighted the conflicts between patient activists who want insurance executives removed from medical decisions and insurance industry leaders who want limits to keep costs under control.
The state laws do nothing for some 60 million people whose employers use self-insured plans, said Ron Pollack of Families USA, a liberal group that has been lobbying for a federal patients' rights bill. "The decisions for them will continue to be made by health plans who will act as the judge, jury and prosecutors in those appeals," he said.
A federal patients' bill of rights would give people in self-insured plans the right to independent review and help people in the eight states without such laws.
Employers and their HMOs had argued that they were not opposed to independent review boards, but wanted one standard instead of the hodgepodge of state laws.
"It's very confusing now for patients, for employers and for anyone who is involved in health care," said Karen Ignagni, president of the American Association of Health Plans, an HMO trade group.
The state laws are intended to let people get second opinions from doctors not affiliated with the HMO, and sometimes force health maintenance organizations to pay up if the independent review shows a surgery or other care is justified.
Dissenting Justice Clarence Thomas said 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."
Neil Trautwein, a spokesman for the National Association of Manufacturers, said the decision invites "crazy-quilt state regulation."
The laws have become popular with legislatures in the past few years. When they are used, they're successful only about half the time, studies have shown.
"What patients have in many states is not that terrific," said Karen Pollitz, a health policy researcher at Georgetown University.
She said the Supreme Court ruling could take pressure off Congress to give broader protections.
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.
Thomas was joined in his dissent by Chief Justice William H. Rehnquist and Justices Antonin Scalia and Anthony M. Kennedy.
The case is Rush Prudential HMO v. Moran, 00-1021.