Assembly OKs Bill on HMOs

SACRAMENTO —  The Assembly approved a bill Thursday that would give doctors the responsibility of making decisions about disputed patient care rather than bureaucrats in managed care plans.

The bill, by Assemblywoman Liz Figueroa (D-Fremont), was passed on a 43-19 vote, with Democrats largely in support and Republicans with sentiments divided or not voiced. Three Republicans voted for the bill; 14 did not vote.

Figueroa said medical treatment should be solely the province of medical professionals and “not a business decision,” a theme she has pursued in other legislation that, for example, allows women 48-hour hospital stays after mastectomies.

In cases in which the treating physician recommends care that an HMO or insurer refuses to cover, Figueroa’s bill (AB 794) would provide for the case to be referred to a second doctor or other health care professional.

The bill would require the second medical professional to be in the same specialty as the first, be licensed in California and that a diagnosis be based on a physical examination.

The HMO could still deny the care, but its liability for malpractice would skyrocket if both doctors agreed on a prescribed course of treatment, according to proponents.

Although philosophically opposed to the bill, Republican Assemblyman Bernie Richter (R-Chico) called it the kind of public interest measure he had no choice but to support, and he voted aye.

The measure--along with several others clamping down on HMO practices that have passed--in the Assembly--now goes to the Senate.

Senate Leader Bill Lockyer (D-Hayward) said the upper house will attempt to find “the right balance between costs and quality of care.”

A spokesman for Gov. Pete Wilson said that although the governor has not taken a position on the Figueroa bill, some provisions “appear problematic,” including added health care costs and what the spokesman called seemingly unnecessary and overlapping procedures to resolve disputes.

An opponent of the measure, Mark Sektnan of the California Assn. of Health Plans, called it the most far-reaching yet and, if enacted, “will drive up health care costs in California 3% to 4%.”

Peter O’Neill, a spokesman for Blue Cross of California in Woodland Hills, said remedies to resolve disputes between doctors and insurers are already in place, including appeal rights for the treating physician.

But Jamie Court, with Consumers for Quality Care, a co-sponsor of the legislation, hailed Thursday’s vote, calling the bill “the first in the nation to prevent HMO bureaucrats from making life and death decisions.”

Beth Capell, with the consumer organization Health Access, the other co-sponsor, said the bill “shifts the balance of power back to physicians and patients” and would prevent practices such as making coverage decisions from locations far removed from the patient.