BETSY MCCAUGHEY ROSS: MAKING MANAGED CARE WORK
In an exclusive two-part interview, AMERICAN HEALTH LINEThis is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.
speaks with New York Lieutenant Governor Betsy McCaughey Ross (R)
about consumer protections under managed care.
AMERICAN HEALTH LINE: What do you think is the major problem
with the health care system today?
McCAUGHEY ROSS: I believe insurance company abuse is the single
largest health problem in America today. My single greatest
concern is that under managed care too many patients who are
seriously ill do not have access to the kinds of treatments that
can keep them alive. If you get cancer or AIDS or many other
life-threatening diseases, there is a strong likelihood that your
doctor will tell you that you need a bone marrow transplant or
high-dose chemotherapy or some other treatment that is still
classified as experimental. In most states, including New York,
your insurance company can refuse to pay for the treatment that
your doctor says that you need to stay alive. And, in every
state except California, once your insurance company says "no,"
your only right of appeal is to the same company that just turned
I have drafted legislation, called the Patient Fair Appeals Act
(SB 2887) that would require insurance companies doing business
in New York state to pay for bone marrow transplants, high-dose
chemotherapy and other treatments that are classified as
experimental if a physician recommends it as the best possible
option to save a patient's life. And, if an insurer refuses, the
patient would have an immediate right of appeal within 15 days to
a panel of three physicians who are experts in the condition and
have no connection with the insurance company. California passed
similar legislation last September -- the first state to do it --
and I believe that New Yorkers and all Americans deserve the same
In addition, as HMOs have closed the door on clinical trials,
cancer research has really come into peril because clinical
trials are where medical breakthroughs occur. Clinical trials
not only save the lives of patients today, but benefit future
generations as well because today's experiment often becomes
AMERICAN HEALTH LINE: What about the insurance companies that
say this will increase costs?
McCAUGHEY ROSS: I want to get right to this cost issue because
it is the most important. Insurers have argued that mandating
access to experimental treatments within a clinical trial will
make health insurance unaffordable. The facts prove just the
opposite. In Seattle, the Frederick Hutchinson Cancer Center
worked closely with Washington state to develop a cost model.
They have demonstrated that mandating access to experimental
treatments would increase total health expenditures in that state
by less than a half a percent. Rhode Island mandated insurance
coverage for certain clinical trials two years ago and found no
adverse cost impact on its two largest insurers, including its
Blue Cross plan.
Perhaps the most revealing study, however, will soon be announced
by the Memorial Sloan-Kettering Cancer Center. They found that
for certain kinds of cancer -- including colon cancer -- patients
who have access to state-of-the-art treatments in clinical trials
actually have shorter hospital stays, fewer return trips to the
hospital and an overall lower cost of care than patients who were
denied access to the clinical trials.
AMERICAN HEALTH LINE: Do you feel that across-the-board
regulation of managed care is the best way to protect consumers?
McCAUGHEY ROSS: I believe in the functioning of the marketplace.
But the marketplace can't work if consumers don't get the facts
to choose wisely. I believe that the health care industry has
failed to meet American marketplace standards for disclosure and
due process. And by doing so, they have invited the heavy hand
of government regulation. I rarely advocate government
regulation, but here it is needed because the industry has failed
the American public. I don't want to mince words on it, I think
that it is tragic that the insurance industry has so disappointed
American consumer expectations.
AMERICAN HEALTH LINE: What do you think needs to happen to meet
McCAUGHEY ROSS: Above all I think disclosure is fundamental. It
is one of the most important aspects because right now patients
and employers cannot get the facts to choose the safest health
plan. I believe that on the federal level, Charlie Norwood's
bill, "The Patient Access to Responsible Care Act" (see AHL
4/14), would accomplish that. It requires insurers to disclose
in plain language in their promotional literature the facts
needed to choose a safe health plan. It would compel insurers to
disclose their loss ratio. I find it a revealing choice of words
-- they consider how much they spend on health care a loss. The
loss ratio is not a perfect indication -- some insurers are
simply more efficient than others -- but you ought to know how
much of your premium dollar will actually be spent on health care
as opposed to marketing, administration and profit. It would
also require insurers to disclose the financial arrangements and
incentives they use to discourage your doctor from providing you
with care, including the withhold.
I have been carrying on a sort of solo campaign in New York state
since I took office to require insurance companies to disclose
the withhold, because if your doctor's going to be paid a bonus
for not referring you to a specialist you ought to know before
you sign up for that insurance plan. Norwood's bill would also
require disclosure of the facts about utilization review -- the
actual limits on your own doctor's decision making. And it would
require health plans to tell you what percentage of the time they
refuse to pay for care recommended by patients' physicians. So
this is a very important piece of legislation (Courtright,
AMERICAN HEALTH LINE, 5/16).