In today’s health-care world, increasingly dictated by insurance companies over physicians’ expertise, it is encouraging that the Hawaii Supreme Court is expediting a lawsuit that has hefty potential to aid those who really matter: the patients.
In a surprising move last week, Hawaii’s high court directly transferred the case — Nitta et al. vs. Hawaii Medical Service Association — to itself, bypassing the Intermediate Court of Appeals. That was good to see, given the precedent this consequential case might have over health-insurance prior authorization or “pre-authorization,” a process that could have life-or-death bearing on other patients’ medical care going forward. A court date is eagerly awaited.
The 2022 lawsuit against HMSA was filed by Hilo obstetrician-gynecologist Frederick Nitta, claiming the insurer failed to cover certain medications and treatments he considered necessary for patients. The suit cites various incidents involving about 30 patients who were denied needed care by HMSA’s preauthorization process: one contract was for Charlene Orcino, whose prescribed pregnancy medication was denied coverage by HMSA; her condition worsened and she was medivaced to Oahu, where she gave birth “dangerously prematurely” to a son who weighed less than 3 pounds.
Nitta’s lawsuit claims that HMSA’s rejections of his diagnoses or treatments forced patients to forego treatment or pay for it without coverage, despite paying for insurance. In some cases, it alleges, HMSA changed the proposed treatment to something unhelpful, even detrimental.
The lawsuit was joined by the family of Scott Norton — not a patient of Nitta’s — who was initially denied a doctor-recommended MRI for his back pain by HMSA. In that sad but compelling case, his family contends that the months of delay in detecting Norton’s prostate cancer, which had spread to his back, spine, hip and ribs, contributed to his death last November.
A forceful ruling against HMSA came in February from Circuit Judge Robert D.S. Kim of Kona, who wrote: “The HMSA agreements wrongfully infringe on the practice of medicine between the physician and patient.” The judge found that HMSA used its power to force doctors to sign unfair contracts that he called “unconscionable” and “unenforceable.”
For many patients and doctors who have encountered health-insurance bureaucracy — or worse, been denied preauthorization for a physician-indicated treatment or medication — this case resonates. Some physicians have expressed worries about speaking up, given
HMSA’s dominance covering more than half of Hawaii’s population.
After HMSA appealed Kim’s ruling, the lawsuit could have been in the appellate court for years. So having the Supreme Court take on this issue in a timely manner should bring clarity — and hopefully, some welcome support for doctors and patients seeking medical treatment.
Not surprisingly, HMSA is curbing expectations about this case, and its impact.
“HMSA understands that the procedural issues presented by this appeal may have been accepted by the Supreme Court to streamline the appeal process, and we look forward to resolving this limited procedural question for this one specific case,” HMSA Communications Vice President Christine Hirasa said. “As we have shared before, this issue does not impact other HMSA provider or member agreements.”
With due respect to HMSA, though, it’s hard to see how it could not. If this and other Hawaii health insurers hear clearly and firmly from Hawaii’s high court that medical care is to be prescribed by a patient’s physician — and not by an insurance officer — that’s powerful.
To be sure, health insurers need to do risk assessments to help protect against such realities as fraud, physician overbilling or overtreatment. But overstepping to favor the bottom line, or intimidation that quells crucial medical care, is indefensible.
At the very least, win or lose, this case should seriously press medical insurers to reassess their reimbursement structures, with an eye on improving quality of care statewide.
As rightly noted by Dr. Nitta: “It’s not about me. I’m
irrelevant. What’s important is that the patients get the care that they need without the insurance carrier interfering and altering or preventing the care.”
