REGULATION: STATES SEARCH FOR A GLOBAL SOLUTION
As some of the states wrap up their 1997 legislativeThis is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.
sessions, it appears that many lawmakers are taking the warnings
about legislating managed care standards "body part by body part"
to heart. While there is still an onslaught of legislation
attempting to counter concerns about alleged managed care abuses
-- Vermont alone has 17 mandates pending that deal with
everything from off-label cancer treatments to coverage of
craniofacial disorders -- there are early signs that efforts to
"manage" managed care are moving away from specific mandates to
attempts to craft global solutions. Such solutions attempt to
create a framework to ensure quality without a law for every body
part and medical procedure.
GOING, GOING...: The recently ended legislative sessions in
Maryland and Georgia are prime examples of what may be the
beginning of the end of the managed care mandate bandwagon.
While both states saw the introduction of a plethora of health
care related bills, 93 in Maryland and more than 200 in Georgia,
mandates dealing with minimum hospital stays for mastectomies --
one of the hottest issues right now in managed care -- failed to
pass in either state. While Maryland did pass some minor
mandates involving coverage for diabetes education and treatment
and osteoporosis and prostate cancer testing, bills that would
have mandated hospital coverage for catheterizations, direct
access to OB/GYNs and payment for follow-up emergency care
services died. The Georgia Legislature turned back a diabetes
bill that was similar to the Maryland measure. And, while
Georgia did bar insurers from refusing to pay for emergency room
services performed under the direction of an attending physician,
it declined a mental health parity bill and a bill that would
require HMOs to give members an appointment within four days.
NATURAL EVOLUTION: Overall, a pattern has emerged in the
evolution of managed care legislation. The earliest bills
attempted to deal with consumer and provider complaints regarding
specific medical situations, such as the length of hospital stays
following childbirth or the failure of HMOs to pay for certain
emergency services. The second tier of legislation, which
emerged over the past year, included attempts to empower both
physicians and patients to deal with managed care, such as anti-
"gag" clause bills, bills to limit physician incentives to deny
care and bills establishing consumer appeals processes. Now,
states are going one step beyond this level to develop unified
approaches to ensuring standards of care.
MALPRACTICE AWARD: One approach would place the onus for
providing quality care on managed care plans by making them
legally responsible for medical decisionmaking. Although managed
care plans have touted their ability to control costs and ensure
quality through strict monitoring of the provision of care, they
have steadfastly maintained that individual physicians are liable
for specific medical decisions. The Texas Senate has passed a
bill that would allow patients to sue managed care plans for
malpractice. The bill has passed out of the House Insurance
Committee and is awaiting scheduling on the House floor.
However, Gov. George Bush (R) has warned that he will veto such a
measure. Other states attempting to open HMOs up to similar
liability include Missouri, California, Connecticut and Ohio.
However, a similar measure failed in Maryland, as did a Georgia
bill that would have required managed care plans to exercise a
minimum standard of care or be open to liability.
CREATIVE APPROACHES: States are also taking other
approaches to guaranteeing minimum standards of care without
specific mandates. A bill pending in Vermont would require
insurers to cover "medically necessary treatment," and empower
the state insurance commissioner to appoint a review panel to
determine if denied treatment is medically necessary. California
is moving to put the length-of-hospital-stay issue to rest by
requiring that a family member or other caregiver be able and
available to care for a discharged patient and that "home
caregivers have demonstrated competency in providing the care the
patient needs." Similarly, an omnibus managed health care
patient protection act introduced in the Massachusetts
Legislature would direct the state Department of Public Health
and the state Division of Insurance to assign minimum lengths-of-
stays to certain surgical, nonsurgical and diagnostic procedures
and treatments. However, a bill failed in Maryland that would
have prohibited insurers from denying longer inpatient
hospitalizations "based on certain treatment protocols or
guidelines." Another potentially groundbreaking piece of
legislation that would have created a state review panel to
analyze the economic and social impact of new health insurance
mandates died in the closing minutes of the Maryland legislative
session -- a sign both of the recognition of the problem of over-
mandating managed care and the difficulty in find a better way to
do it (Miller, AMERICAN HEALTH LINE, 4/11).