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Legislator Sees Health Care As Key Issue This Session w/ cut

B Y K AAREN V ALENTA

Health care administrators and town officials gathered January 17 at Ashlar of

Newtown to listen to State Rep Julia Wasserman (R-106) discuss health care

issues facing the 1997 General Assembly.

A six-year member of the Public Health Committee, Rep Wasserman this year

switched to the Program Review and Investigations Committee, where she is the

ranking member.

"This is a key bi-partisan committee with a 15-member professional staff in

the medical and social sciences field," she said. "The committee decides which

six or seven issues will be investigated. Last year it was HMO/managed care

and nursing homes."

The investigative staff's findings and recommendations have just been

submitted to the committee and they are "far-reaching," she said. "They will

be controversial.

"They will tend to raise the insurance premiums in the health field," she

warned.

The report concluded that managed health care plans are working well, lowering

the cost of health care benefits and increasing access to health care. At the

same time, managed care plans are receiving good ratings by consumers, the

report said.

Despite these findings, the report concluded Connecticut's regulatory

structure should be strengthened and improved, a recommendation Rep Wasserman

did not enthusiastically support.

A consistent opponent of "any willing provider" proposals, Rep Wasserman said

she is in favor of managed care - if there are good controls - as a way of

providing good medical care at a reasonable cost.

But much of the detailed statistics and other information which HMOs would be

required to compile as part of the committee's recommendations may never be

used, she warned, and this paperwork will drive up costs.

"Managed care was meant to lower costs, but I believe things we will legislate

this year will tend to increase costs," she said.

Despite many accusations and complaints leveled at managed care plans by some

health care providers and patients, the committee's six-month study showed

such complaints received by the Connecticut Department of Insurance amount to

less than half a percent (.03 percent) of all HMO enrollees. These complaints

have declined even as the number of persons covered by these plans have

dramatically increased.

The report also concluded that decisions to deny the use of a treatment or

procedure are currently being made by licensed health care professionals

within utilization review committees, not by clerks, as has been alleged by

critics of managed care. Other conclusions included:

Although many Connecticut HMOs use pre-established standards to help determine

whether treatments are appropriate and therefore reimbursable, actual

practices typically exceed the standards. Outpatient mastectomies, for

instance, are rare, with the average length of stay ranging from 1.5 to 3.5

days.

Physician concerns about being dropped or "de-selected" by health plans are

not supported by data. Very few providers have failed to have their contracts

renewed.

The state Department of Insurance is diligent in its oversight role and should

not be replaced by another agency, such as the Department of Public Health.

Purchasers of health plans are the best judges of the levels of quality and

access standards they wish - legislating those standards is unwarranted and

premature in a health system that is changing rapidly.

Mandates such as "any willing provider" options, that allow enrollees to use

any out-of-network providers, severely limit a plan's ability to negotiate

reasonable prices and contain costs, the report said.

State government agencies are ill-suited to conduct appeals over whether a

treatment or procedure is medically necessary. State statutes which require a

minimum length of stay for any procedure could obstruct progress at further

reducing length of stay under sound medical practices and is an unnecessary

intrusion into the area of medicine.

"Decisions, such as length of hospital stay after surgery, should be made by

doctors," Rep Wasserman said. "The legislature should not have to legislate

this and certainly should not do it piecemeal. I don't think this is the way

to go."

The report recommended there should be an independent board of medical

practitioners to which consumers could appeal the denials of medical

procedures or treatments. Notification standards should be set for terminating

providers from networks and there should be a prohibition against "gag

clauses" in provider contracts.

The Program Review and Investigations Committee has voted to draft a bill

based on the report's recommendations and a public hearing is expected soon,

Rep Wasserman said.

Barry M. Spero, president and chief executive officer of Masonicare, which

operates Ashlar of Newtown and other nursing homes, said health care benefits

are being "driven by the bottom line" and nursing homes are becoming unable to

offer "little things, like beauty shops, that are part of the quality of life"

for the residents.

Louise Bailey, governmental affairs coordinator for Masonic Geriatric

Healthcare Center in Wallingford, agreed, adding that nursing home rates have

not been increased in years. She is asking Rep Wasserman to use her influence

to get a review of federal/state Medicare funding.

All agreed that health care issues are continually becoming more complicated.

"You get into one area and that raises other questions," Mr Spero said. "They

affect everyone because health care is necessary for us all."