The standards, practice guidelines, coverage limitations, and so forth, that managed care organizations use should not be a black box. Patients and their doctors should know what's covered and what's available. Moreover, disclosure should be active not passive. That is, the rules should not be fine print, but communicated dynamically, when they are relevant to treatment decisions. A timely appeals process for coverage denials is essential .
Confidence depends on a sense of fairness and due process.
In California last year our group, along with the California Medical Association, successfully sponsored legislation to establish a third-party appeals process in cases in which patients are denied coverage on the basis of a medical technology's being considered experimental. In regard to leading-edge technologies, it seems fitting that the federal government increase its commitment to clinical research, just as it sponsors basic life sciences research and graduate medical education. The recent debate over the value of routine mammography in women under 50 year old to screen for breast cancer is a perfect example of a crucial medical question that can only be fully addressed with sufficient federal data and federal sponsorship. By the same token, the Food and Drug Administration performs a unique, essential function in reviewing new technologies for safety and efficacy. The application of the tool constitutes the practice of medicine, that is, a matter to be decided within the context of the physician-patient relationship.