Doctors, legislators take on managed care

Government regulation may increase

Bipartisan federal legislation and efforts by the American Medical Association are the latest developments to address consumer concerns that managed care organizations are sacrificing quality of care for cost efficiencies.

Some physicians who advocate the need for government intervention say it will level the playing field for all managed care organizations. The best managed care companies already do what is required by proposed legislation, says Arthur Safran, MD, a public policy fellow with the American Academy of Neurology, who is currently leading an effort to get a "Health Insurance Bill of Rights" passed in the U.S. Senate. The measure was introduced by Sen. Edward Kennedy (D-MA) and has bipartisan support.

Competing on quality

Proposals with similar goals have been introduced in the House of Representatives and in many state legislatures. The provisions will "allow manage care organizations to compete on quality, not just cost," says Safran.

Many of the provisions in these legislative proposals mirror the original Bill of Rights, as the first 10 amendments to the U.S. Constitution are collectively known. The key elements of the bill currently before the Senate include the following:

• A plan may not deny coverage for emergency care assessment and stabilization "if a prudent layperson would seek such care given the symptoms experienced."

• Enrollees with life-threatening, chronic, degenerative, or other serious conditions that require specialty care must be given access to the appropriate specialists or "centers of excellence." If a plan does not have a participating specialist for a condition covered under the plan, the plan must refer the patient to a non-participating specialist at no additional cost to the patient.

• If an enrollee has a serious condition for which there is no effective standard treatment and is eligible for an approved clinical trial that offers the potential for substantial clinical benefit, the plan must pay for the routine patient costs of participation in the trial.

• If a plan provides benefits for prescription drugs within a formulary, the plan must allow physicians to participate in the development of the plan formulary, disclose the nature of formulary restrictions, and provide exceptions when medically necessary.

• The plan may not prohibit or restrict the provider from engaging in medical communications with the enrollee.

• Plans must describe and make available to current and prospective enrollees the following information:

— procedures for obtaining emergency care or care outside normal business hours;

— any financial incentives that may affect the treatment of the enrollee;

— provisions of the plan’s utilization-review requirements;

— all treatment options;

— how the plan addresses the needs of non-English-speaking enrollees and others with special communication needs;

— specific grievance procedures as required by the legislation.

• There must be grievance procedures that include a two-stage review process that is supervised by a licensed physician. The legislation also would create and fund an Office of Health Insurance Ombudsman in all 50 states. The assistance would include complaints, appeals of care, and selection of a health insurance plan.

Safran predicts the legislation will pass this year for the following reasons:

— There is an enormous amount of public support for change in the current system.

— The bill has bipartisan support.

— The proposal was developed "through substantial negations with medical specialty groups, consumer groups, and health industry leaders," he says. The drafters also reviewed all current state proposals on managed care regulation and incorporated some of these ideas into the Senate bill.

Meanwhile, the AMA is working to make sure the medical profession maintains its high standing among the public. In March, the professional group announced the formation of an Institute for Ethics. Managed care will be one of the Institute’s four areas of emphasis. Led by Linda Emanuel, MD, PhD, the institute will identify ethical issues arising from managed care, conduct research to measure the ethical repercussions of managed care initiatives, and explore various positions regarding managed care policy.

Emanuel says the AMA also plans to develop a database on health delivery organizations and publish "ethics report cards" about health care organizations by the end of the year. Is there a connection between the AMA initiative and legislative proposals? "We are separate but talking to each other," says Emanuel. "Essentially our contention is that any organization that influences patient care should be held accountable to ethical standards and quality standards," she maintains.

The report card program will "leverage the powerful effect of reputation for ethical and unethical conduct. It will insist on professional standards no matter how aggressively commercial the business setting," she says.1


1. Emanuel L. Bringing market medicine to professional account. JAMA 1997; 277:1004-1005.