Managed care backlash bandwagon hits Congress

HMO checks and balances likely

Having taken the political pulse, Congress is expected to pass a major managed care reform proposal. But, not this year—so soon after passage of last year’s health care reform bill.

However, Capitol Hill insiders tell us to look for an anti-managed care legislative package to pass Congress in time to be signed before next year’s November elections.

On the state level, the National Conference of State Legislators predicts between 12 and 25 states will pass comprehensive bills this year increasing consumer protection against managed care practices. Managed care will not be legislated out of existence, but if legislative rumblings become reality you can look for major changes in the way managed care plans are managed.

Trimming back managed care’s influence

This wave of health care reform legislation is generally concerned with six broad efforts aimed at reducing managed care’s current near-absolute authority in certain areas. Most of the major managed care reform legislation at both the state and federal level addresses at least one of these categories:

Direct access. These are clauses that permit patients to be treated by specialists without having to get prior approval from their HMO .

Freedom of choice. These provisions allow patients to see any doctor they want, even if the physician is not part of the HMO’s approved network. Some lawmakers are proposing legislation that would also force plans to automatically accept any qualified doctor into their network.

Anti-financial incentive. HMOs would be prevented from giving doctors any financial inventive to limit medical tests or treatment.

Gag rule. Contracts that stop doctors from telling patients about their full range of treatment options would be banned.

Emergency care. These measures require plans to cover emergency room charges for members who mistakenly thought they had a serious illness requiring ER treatment, when they turned out only to have a minor problem.

Improved grievance proceedings and appeal processes for plan members.

Whatever legislation Washington lawmakers finally agree on will most likely come from this basic menu of options. Sen. Ted Kennedy (D-MA) and Rep. John Dingell (D-MI), for instance, have introduced legislation covering these six elements that is expected to be the starting point for the the coming congressional managed care debate. This legislation bans gag clauses, requires HMOs and doctors to reveal their compensation packages, sets guidelines for grievance procedures, and guarantees that patients with chronic illnesses or serious medical conditions will be able to see a specialist.

It would also stop insurers from denying "medically necessary" services prescribed by the treating physician—meaning the HMO can not overrule the attending physician’s recommendation. Plus, it permits women to see an OB/GYN without first getting a referral from their primary care physician.