MANAGED CARE: Tennessee Bill Sent To Gov., Texas Regs Proposed
The Tennessee Legislature gave final approval this week to the Consumer Health Care Advocacy Act (HB 2949), a measure "aimed at giving consumers more voice in some managed care insurance plans." According to the Memphis Commercial Appeal, the bill would allow patients to choose out-of-network doctors, as long as they agree "to pay higher fees." If a physician is removed from a health plan's network, the bill "would allow patients to continue seeing" the doctor "for 120 days," and women in their second trimester of pregnancy could "continue seeing" their doctor "through birth." Additionally, HB 2949 "requires managed care organizations to accept into their network any pharmacists willing to abide by the organizations' financial contracts," and health plans would be prohibited from "kicking a doctor out" of their network "because the physician was advocating on behalf of a patient."
A Consensus Bill
The Commercial Appeal notes that the bill "represents a consensus of business, insurance companies and some in the medical profession." HB 2949 "applies only to state-chartered, private health insurance companies -- about a third of those operating in Tennessee, according to committee testimony" (Branson, 4/30). The bill is being forwarded to Gov. Don Sundquist (R) for his final approval. According to a Sundquist spokesperson, the governor "is likely to sign" the bill but is withholding a final decision until he reviews its final language (American Health Line interview, 4/30).
Texas Releases Draft Managed Care Regs
The Texas Department of Insurance this week posted draft managed care regulations that "would force health maintenance organizations to pay for in vitro fertilization, unlimited home health care and diabetes equipment," the Dallas Morning News reports. The regulations, which can be viewed online at www.tdi.state.tx.us, are intended to enforce "15 new laws passed during the 1997 legislative session." Health plan officials "are most concerned by the draft rules that dictate mandatory coverage." Prudential HealthCare of North Texas' Carl King said, "The Legislature was very vigorous in its desire to address perceived managed-care ills. We believe that the marketplace and the satisfaction statistics that most managed-care plans enjoy suggest that excessive regulation really is not necessary."
The Dallas Morning News outlines what is in the draft managed care regulations:
- "At least one primary-care physician for every 1,500 HMO enrollees and one gynecologist for every 3,000 enrollees";
- Health plans must provide members with 24-hour access to urgent care, "routine visits within two weeks, adult preventive-care visits within two months and child preventive-care visits within one month";
- "Mandatory coverage for inpatient and outpatient hospital services, rehabilitation, mastectomy and breast reconstruction, mental health services, chemical dependency, prostate cancer tests, annual eye and ear checks for children, immunizations and mammography";
- Women must be provided "direct access to a gynecologist";
- Health plans would be prohibited from removing medications from their formularies "in the middle of a contract year";
- Plans would have to disclose "substantial changes in financial incentives to physicians." In addition, state "regulators are considering mandatory treatment for severe obesity, breast reduction surgery, as well as requiring plans to provide prescription drugs and blood plasma treatments for hemophiliacs."
"[M]ost observers are withholding judgment" on the proposed regulations "until they have more time to study them." Texas Medical Association attorney C.J. Francisco said, "Rules have a tendency to interrelate with each other. Until you finish, you really can't sit back and see what the picture as a whole looks like. I think they have addressed some issues that are of interest to physicians and patients." Jeff Kloster, general counsel for the Texas Association of Health Plans, noted the impact that uncertainty about regulations can have on health plans: "The ink is not dry on a lot of contracts out there in the marketplace, only to find that we have to change them yet again. One of these days, we have to finally settle down and say these are the rules of the game and we have to live with it" (Ornstein, 4/30).