HMO-PROVIDER POLICIES: PATIENT NEEDS MOVING TO FOREFRONT
The needs and interests of patients appear to be the mainThis is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.
catalysts behind two recent moves in the managed care industry.
The California Public Employees' Retirement System (CalPERS)
announced Tuesday that is going to charge "severe financial
penalties" to health plans and medical groups that "force
patients to switch doctors or change plans" (Chiu, Sacramento
BEE, 10/1). In Dallas, United HealthCare Corp.'s MetraHealth HMO
will soon begin offering the area's first open access HMO in
which members can go directly to specialists without having to
first visit a primary care gatekeeper (Deener, DALLAS MORNING
I'M GOING BACK TO CALI: "We want to put the health plans
and providers on notice we've reached the end of the line," said
Margaret Stanley, CalPERS assistant executive officer of health
benefits services. The BEE reports that CalPERS has seen nine
health plans and 30 provider groups "sever" their contractual
ties during the past year. The decision to penalize groups that
cause patients to switch providers was prompted by last week's
announcement by Foundation Health and the University of
California at Davis Medical Center that they were cancelling
their contract. That change will force 11,700 Sacramento-area
residents to change physicians "during the next month." In an
effort to get the two groups to rejoin, CalPERS took out a full
page ad in the BEE that read: "Enough is enough. Is the money
more important than your patients?"
POLICY CHANGE: According to the BEE, "some of the penalty
clauses could range from fines to guarantees that would lock
health plans and doctor groups into service for the entire
contract year." All health plans and doctor groups currently
have long-term contracts, but "most have 30-day out clauses."
CalPERS Communications Director Pat Macht said, "The continuous
forced re-enrollment is creating havoc for our members and for
PERS." Foundation's California health plan CEO and President
Gary Velasquez said that he would "welcome" the new requirements,
but added that "a lot of thought would need to go into them." He
said that "[u]nder some circumstances, such as to protect
quality, health plans need to be able to cancel contracts."
CalPERS' Stanley said she hopes other corporations and groups
will join them in demanding more "patient service guarantees."
She said, "We are tired of our members being put last in this
profit-induced shuffle game" (10/1).
THAT'S HOW ITS DONE IN TEXAS: In an effort to eliminate the
complaint that "HMOs make it too difficult for patients to see
medical specialists," MetraHealth's Dallas plan will begin
offering an open access plan starting next week. "We'll not even
require our members to select a primary care physician if they
don't want to," said Richard Cook, CEO of MetraHealth's Dallas
operation. MORNING NEWS reports that premiums for the plan will
be about one percent to three percent higher than the gatekeeper
HMO plan, but "considerably less than for traditional fee-for-
GOOD FOR PATIENTS & BUSINESS: MetraHealth believes that
costs will not be higher in the open access plan compared to the
gatekeeper plan because "the vast majority of members continue to
go to their primary care physicians without being forced." Cook
said, "People just don't like being told what to do. But left
alone, they will usually do the right thing." MetraHealth parent
United HealthCare's open-access HMOs in Atlanta and Columbus, OH,
"had the lowest medical costs per member of any HMOs in those
states," during 1992 to 1995, according to United Chief Medical
Officer Lee Newcomer. In St. Louis, where united operates both a
gatekeeper and an open-access HMO, "the costs were almost
identical." Competitors say MetraHealth is just trying to boost
market share and "have no immediate plans to imitate the
service," according to the MORNING NEWS (10/1).