Lawmakers taking aim at HMOs
Lawmakers taking aim at HMOs
Draft laws prohibit gag clauses, improve access
Pick up a newspaper, turn on the television, or sit in a state or federal legislative chamber and you will hear a similar story: tales of skirmishes in the ongoing war between doctors and health maintenance organizations (HMOs) abound.
Sometimes they are minor annoyances, such as the recent controversy over "drive-by deliveries" forcing new mothers to leave the hospital within 24 hours after giving birth. Other times they are dangerous gambles that prove life-threatening, such as the woman whose colon cancer was misdiagnosed as irritable bowel syndrome. Her HMO, Group Health Association, required her doctor to submit a special request before she could see a specialist and take the test that might have exposed the disease. Since such requests had been denied in the past by the HMO gatekeepers, the doctor didn’t bother to request it. The cancer was not diagnosed until a year later, when the tumor blocking her colon required emergency surgery.1
In May 1996, the subcommittee on health and the environment of the U.S. House energy and commerce committee heard several cases that further illustrate the tense nature of these flare-ups in testimony from representatives of the American Medical Association and the Cystic Fibrosis Foundation:
• A Tulsa, OK, physician was threatened with possible loss of his HMO contract (often called "deselection") when he wrote to his patient that the HMO refused to authorize a magnetic resonance arteriogram (MRA) because the plan considered the procedure "investigational." He also explained that an alternative test requiring injecting dye into the patient’s arteries was riskier than the MRA.
Upon receiving a copy of the doctor’s letter, the HMO wrote him that his actions were considered to be "significantly inflammatory." "You should be aware that a consistent pattern of pitting the HMO against its members may place your relationship with [the plan] in jeopardy. In the future, I trust you will choose to direct your concerns to my office rather than in this manner."2
• An eight-year-old boy had significant lung disease but was denied visits to his local cystic fibrosis care center for routine checkups and ongoing treatment for the complexities of the disease. The boy’s HMO physician denied the coverage based on a belief that aggressive treatment was inappropriate because there was lack of a "good prognosis" for patients with the disease.2
Now members of Congress, as well as legislators in at least 15 states, have enacted or introduced legislation in the last year to ban "gag clauses" in HMO contracts and require access to appropriate specialty care.
According to the Washington, DC-based American Association of Health Plans (AAHP), more than 1,000 bills were introduced last year that would have affected HMOs. During the first six months of 1996 alone, 33 states passed new managed care regulations, and another nine have signaled their intent to do so in 1997.
Here is a synopsis of state laws:
• Nine states have passed legislation to ensure access to emergency care and prohibit prior authorization requirements.
• Eighteen states require HMOs to provide direct access to OB/GYNs.
• Thirteen states require managed care plans to provide a range of new information for enrollees.
• Nine states mandate additional provider due process protections.
• Six states have established stronger utilization review criteria.
Federal law introduced
The Managed Care Consumer Protection Act of 1997 was introduced in January by Rep. Pete Stark (D-CA), ranking minority leader of the powerful U.S. House ways and means subcommittee on health. "Past tragedies might have been avoided if the patients had known about the financial incentives not to treat, or if the physicians had not been gagged from discussing treatment options, or if there had been legislation forcing health plans to provide timely grievance procedures and timely access to care," Stark wrote in a letter to colleagues asking them to cosponsor the comprehensive bill that would regulate Medicare managed care and private plans.
In January, a bipartisan group of legislators from nine states announced their intent to introduce legislation regulating managed care organizations similar to the proposed federal law. Versions of the bill have been or soon will be introduced in New Jersey, Texas, Colorado, Georgia, Delaware, Kansas, Ohio, Oregon, and Tennessee.
"These nine legislators saw beyond the current patchwork of legislation to regulate the rapidly growing managed care industry and fashioned a comprehensive bill that protects consumer rights without hobbling managed care plans with mandates and micromanagement," says Joy Newton, executive director of Women in Government, a bi-partisan educational association for elected and appointed women in state government. Based in Washington, DC, the group joined the legislators in making the announcement.
References
1. Hilzenrath DS. Cutting Costs Or Quality? Washington Post, Aug. 4, 1995.
2. Families USA Foundation. HMO Consumers at Risk: States to the Rescue. 1996. Washington, DC.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.