Clip file / Local news from the states
Clip file / Local news from the states
Each month, this column features selected short items about state health care policy digested from publications from around the country.
Texas suit challenges legality of financial incentives HMOs give to physicians
AUSTIN, TX—Health maintenance organizations’ financial incentives for physicians violate state laws against incentives for limiting care, according to three suits filed by Texas Attorney General Dan Morales against six managed care plans in mid-December.
Observers say the action is the largest taken against the managed care industry in state history.
Aetna owns four of the six plans named: Aetna U.S. Healthcare, Aetna Health Plans of North Texas, NYLCare Health Plans of the Southwest, and NYLCare Health Plans of the Gulf Coast. Also named in separate suits are Humana Health Plans of Texas and PacifiCare of Texas.
All three companies denied the accusations and said they were surprised by the suits because they had been discussing the contracts with Morales’ office for several months.
In August, the Texas Department of Insurance settled a similar complaint against Harris Methodist Health Plan, a large north Texas HMO. In a consent order, Harris agreed to rewrite contracts and to reimburse physicians.
"We cannot allow the accountants and lawyers at the HMOs to make decisions about what is proper medical care for patients," Mr. Morales said in a prepared statement. "That is a decision reserved for patients’ doctors, and those doctors should not be manipulated by the HMOs."
The suits are being brought under a 1997 state law that forbids HMOs from using any "financial incentive" or "payment . . . that acts directly or indirectly as an inducement to limit medically necessary services." The suits ask that the companies be fined and prevented from continuing the practices.
The defendants also are accused of providing members with deceptive or untruthful information regarding coverage for emergency services, prescription drugs, and referrals to specialists as well as misrepresenting the timeliness of handling claims.
—Dallas Morning News, Dec. 17; Fort Worth Star-Telegram, Dec. 16
Washington State gets the help of pharmacists to expand access to emergency birth control
SEATTLE—Washington State pharmacists wrote 2,765 prescriptions for emergency contraception in the first four months of a project encouraging access to the drug through pharmacist collaborative agreements.
A study published in November/December Family Planning Perspectives calls the response to the project "overwhelmingly positive." One major pharmaceutical chain that previously had averaged about one prescription for emergency contraception per week filled an average of 61 per week during the project. About 500 pharmacists at 111 pharmacies participated in the initiative.
Washington is one of 22 states that allow pharmacists to prescribe drugs under collaborative agreements with a "prescriber," a physician or nurse practitioner. By August 1998, the Washington Board of Pharmacy had approved 117 protocols specifying the conditions under which treatment can be provided. Washington law is relatively liberal and does not place any restriction on the type of drug or location of practice.
The authors conclude that pharmacists can play an important role in increasing access to emergency contraception and note that as many as 14 states have legislation "favorable" to establishing prescriptive practice agreements.
—Family Planning Perspectives, November/December 1998
Lost in the Medicaid managed care shuffle, public health struggles to regain its footing
WASHINGTON, DC—Medicaid managed care largely has ignored the nation’s public health departments as providers of primary care and other services, thus draining the departments of both patients and revenues. In response, many of the nation’s 3,000 city and county public health departments are de-emphasizing the delivery of services in favor of a return to traditional public health activities such as health promotion or investigating community health problems, concludes a recent issue brief published by the Center for Studying Health System Change in Washington, DC.
The study also found the following:
• Some health departments are pursuing cooperative arrangements with Medicaid managed care plans. Unfortunately, most of these contractual arrangements lack clarity about the role of the health department. Where there is clarity, two models are emerging: reimbursing local health departments for Medicaid services, even outside the formal managed care networks; and requiring Medicaid managed care plans to collaborate with local public health departments on specific services such as infectious disease control.
• Rarely do the states set specific requirements for comprehensive involvement of the public health departments. Some state contracts are more likely to spell out a role for local health departments on a service-by-service basis, particularly infectious diseases. In California, for example, the state contract specifies that tuberculosis patients requiring directly observed therapy be referred to the local health department.
• States have not been as active as they could have been in clarifying a role for health departments in a privatized Medicaid system, but some health departments are finding their own way by developing formal and informal relationships with Medicaid managed care plans. Without such direction, health departments that are more aggressive about partnering with managed care plans can better ensure their place in the local health care system.
The study, Public Health Departments Adapt to Medicaid Managed Care, was written by Rose Marie Martinez and Elizabeth Closter. The Center for Studying Health System Change is funded exclusively by the Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research.
—Center for Studying Health Center Change, excerpted from Issue Brief #16, November 1998
CDC recommends name reporting for HIV infection but wants states to keep anonymous testing
ATLANTA—Public health officials should report the names of people with HIV in their surveillance efforts in the same way they now collect the names of persons with AIDS, the Centers for Disease Control and Prevention recommended in draft surveillance guidelines released Dec. 10.
The guidelines recognized a "greater sensitivity" of HIV case surveillance data compared to AIDS data alone, and said it was "essential" for surveillance programs to strengthen their data-protection efforts. They note that, as of July 1998, 32 states were conducting HIV case surveillance using the same methods as those for AIDS surveillance.
The expanded use of name reporting, according to the guidelines, will allow public health officials to better understand the prevalence and incidence of HIV, particularly among ethnic minorities. However, the CDC supports the continued availability of anonymous testing. The agency "strongly recommends" the repeal of state and local laws prohibiting anonymous testing, "given the overriding public health objective of encouraging knowledge of HIV serologic status."
While not binding on states, the guidelines, if adopted, would represent a "gold standard" with regard to HIV and AIDS surveillance practices. The guidelines can be found on the CDC Web site at www.cdc.gov/nchstp/hiv_aids/dhap.htm.
—Federal Register, Dec. 10
Certificates of Need may control long-term care costs now, but what about the long run?
WASHINGTON, DC—Controlling the supply of nursing homes might serve the ends of the industry and state regulators now, but "it is unclear how well this strategy will work over the long run," concludes a 13-state analysis of Certificate of Need laws completed by The Urban Institute in Washington, DC.
States should turn their attention to alternatives to institutional long-term care, which have taken advantage of "minimal government regulation" to become a growing part of states’ Medicaid and long-term care spending, the report says.
The report notes that home health has eased the pressure for long-term care in the face of limited nursing home availability but questions how long this alternative will be available. The report concludes it is important for state officials to anticipate future long-term care needs and develop the services to meet them. "The care needs of the elderly do not disappear just because no nursing home beds or home health agencies are available," conclude the authors of Controlling the Supply of Long-Term Care Providers at the State Level.
Researchers studied the nursing home industry in Alabama, California, Colorado, Florida, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, Texas, Washington, and Wisconsin.
—A copy of the report is available on the Internet at http:// newfederalism.urban.org/html/occ22.html or by contacting The Urban Institute at (202) 261-5709.
Editorial comments or questions?
Contact State Health Watch at (404) 262-5467 (voice), (404) 262-5447 (fax), or [email protected] (e-mail).
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