Full Text:

Need For Managed Care Oversight

Outweighs Flaws In Bill

B Y S TATE R EP J ULIA W ASSERMAN

Keep it simple and get to the bottom line.

As a guest lecturer at Columbia University, one of the first things I would

tell my postgraduate students is to discern as quickly as possible what is

important. Whether you are writing a thesis or answering a question in the

classroom, my instruction is simple: Keep it simple and get to the bottom

line.

The same should apply to the General Assembly as it goes about writing the

laws that govern this state and its people. Legislation should be as simple as

possible. It should clearly spell out our policy objectives, and leave the

details of implementation to the executive branch agencies and departments

that are responsible for the administration of our state government.

In my view, this is the major shortcoming of HB 6883, An Act Concerning

Managed Care, which passed the House of Representatives on May 8. I recognize

the very valid questions and concerns that have been raised about managed care

and which the bill addresses. At the same time, I believe the legislation goes

beyond the policy-making role of the General Assembly and attempts to

micromanage issues that would best be addressed through the promulgation of

regulations by the executive branch.

Managed care has brought revolutionary change to the delivery of health care

in this state and this country, and that change will continue as the system

continues to evolve. To address each and every concern in statute limits our

ability to respond to this ongoing change because the only way to change a law

once it is enacted is by enacting another law.

I was able to resolve my difficulties over the bill by thinking back to my

work as a college instructor and the advice I gave my students. I sought to

"get to the bottom line." My concerns about micromanaging the issue of managed

care have not evaporated, but I have concluded that the bill is a basically

sound piece of legislation and that it will begin to address the questions and

problems that have been raised about managed care.

The major provisions of HB 6883, as summarized by the Office of Legislative

Research, include:

Requiring the state Department of Insurance, in consultation with the state

Department of Public Health, to develop "consumer report cards" for all

licensed HMOs and other major managed care plans in Connecticut. The report

card would allow consumers to make a better comparison between plans.

An external appeals process through which patients, or their physician or

other provider acting on their behalf, could challenge the denial of coverage

either by the health care plan or its utilization review company. Patients

would first have to go through any internal grievance or appeals process of

the health care plan or utilization review company before they could use the

new appeals process. This external review would operate independent of the

health care plan or utilization review company under the state Department of

Insurance.

Requiring managed care plans to provide their enrollees with an annual list of

all physicians and other providers participating in the plan. Plans also would

have to notify patients as soon as possible when their primary care physician

withdrew from the plan or was terminated.

Requiring that managed care contracts spell out what is or is not covered by

their plan and the copayments, deductibles or other out-of-pocket expenses for

which the patient is responsible.

Prohibiting managed care plans from imposing "gag rules" on physicians or

other providers preventing them from discussing all treatment options,

including experimental treatments, whether they are covered by the patient's

plan or not.

Requiring that coverage for emergency room visits be based on a patient's

symptoms when they first arrive in the emergency room regardless of the final

diagnosis, as long as the symptoms reasonably indicated an emergency medical

condition. This provision makes it more difficult for managed care plans to

deny payment for emergency room care for patients who believe they have an

emergency, which later proves not to be an emergency.

Governor Rowland has indicated that he will sign HB 6883 if it passes the

Senate in its current form, which is expected. The bill would take effect

October 1, when many of the provisions would begin to apply. The first "report

cards" for HMOs and other managed care plans would be due by March 15, 1999.