No. 2 HMO
to give docs
final say-so

UnitedHealth Group's
plan is welcomed by a
Hawaii health coalition

By Helen Altonn
Star-Bulletin

The nation's second-largest health insurer has decided to give doctors the final say on medical care, a historic move that was hailed today by a Hawaii health organization.

UnitedHealth Group has decided to eliminate a type of red tape that has particularly vexed many patients, an official at the health maintenance organization confirmed today.

UnitedHealth expects to announce its new policy tomorrow -- a momentous shift for the HMO industry, the Dallas Morning News reported.

"This is very exciting," said Dr. Arleen Jouxson-Meyers, president of the Hawaii Coalition for Health. "It's really good for patients and certainly good for physicians who take care of them."

A basic tenet of managed health care has been the ability of HMO managers to overrule doctors' decisions about what procedures and services are medically necessary and therefore covered by insurance.

HMO officials say the policy was responsible for reducing the big increases in health costs of the late 1980s and '90s. But doctors and patients across the country have protested that the policy put health-care decisions in the hands of nonmedical people concerned mainly with HMO profits.

UnitedHealth, covering 14.5 million people, found that it was spending $100 million a year nationally to review questionable treatments, then saying yes to 99 percent of them, said Dr. Archelle Georgiou, chief medical officer of the Minneapolis-based company.

"Yet, it was the root cause of many of the negative perceptions of managed care," she told the Dallas Morning News.

Some national experts termed the company's planned move a historic one in managed care and said they expect other insurers to follow suit.

UnitedHealth physicians still will be required under the new system to notify the insured if a patient enters the hospital, requires home health care or needs costly medical equipment, and UnitedHealth may ask for more information. But the treating physician will have the final decision on medical necessity, the company said.

Services such as cosmetic surgery that are not covered under the present contract will still not be paid for. Doctors who fall behind their peers on quality or cost measures could be dropped from the network, Georgiou said, but the first step would be to help them improve.

Clifford Cisco, Hawaii Medical Service Association senior vice president, indicated that UnitedHealth's new policy would have little impact on HMSA, saying its doctors already make all health care decisions relating to their patients.

"That's true in our HMO programs and regular HMSA," he said.

He said HMSA, the state's largest health insurer, over the years has scaled down prior health care approval procedures. "We're trying to make things better and work closer with doctors," he said.

Jouxson-Meyers said, however, that there have been many problems here between doctors and insurers about needed medical treatment.

"This has been the biggest beef against managed health care all this time, that people who are not physicians have the last say in what is done or not done for patients," she said.

"I'm hoping because UnitedHealth is such a big organization that other insurers will take notice of their experience and follow the same path," she said.

She said the insurance commissioner's patients' bill of rights task force will discuss UnitedHealth's new policy at a regular meeting at 9:30 a.m. tomorrow.

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