BETSY MCCAUGHEY ROSS: MAKING MANAGED CARE WORK

      In an exclusive two-part interview, AMERICAN HEALTH LINE
 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
 you down.  

 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
 protection. 

 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
 tomorrow's cure.

 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
 consumer expectations?

 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).