MANAGED CARE: Lawmakers, Hospitals Should Join to Pressure HMOs

     Pointing to the recent decisions by Catholic Healthcare West to stop accepting Blue Cross of California patients and the California Medical Association's lawsuit charging Blue Cross with "a pattern of paying physicians too little and too late," a Los Angeles Times editorial says these actions are "one more sign" that "[d]octors and hospitals are increasingly willing to take their cases to the court of public opinion, and the court of law." Noting that tension is mounting between health care providers and insurers, the editorial suggests that "[s]tate legislators can help" by increasing oversight of insurers' payment practices and patient care. While lawmakers "can do little about the amount being paid" by insurers, the editorial asserts that a bill by Assemblyman Jack Scott (D-Altadena), which would "broaden the power" of the new Department of Managed Care, could help. The measure would authorize the DMC to "audit and penalize health plans that repeatedly delay or deny payment of claims." Although "[l]egislators do not have the expertise or the political mandate to get involved in the business of setting the prices that private insurers pay to health providers," the editorial maintains that lawmakers "can give employers and patients the objective tools they need to accurately assess the quality of a plan's health care." One such program already is underway. The DMC and the Pacific Business Group on Health, a consortium of large employers, are preparing to release a quality assessment of heart bypass surgeries this fall. The editorial urges the DMC to "make good on its promise" by developing similar tools next year to assess several other health quality indicators. Noting that "the biggest victims of the recent upheaval in managed care have been patients, who are rightly concerned about the instability in their plans," the editorial concludes, "Beefing up oversight of insurance payment practices" and "tougher oversight of quality" can help assuage "patient animosity and employer frustration toward managed care" (8/3).