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HMO Regulation

September 06, 1996
By: Andy Kravetz
State Capital Bureau

JEFFERSON CITY - After nearly two weeks of testimony from all sectors of the health care industry, legislators are moving closer to the notion of more regulation of managed care.

Committee Co-chairmen Sen. Joe Maxwell, D-Mexico, and Rep. Tim Harlan, D-Columbia, said on Thursday that they think more regulation is needed for HMOs and the managed care industry as a whole.

"I am in total agreement that there will be recommendations from the committee on rules or legislation on regulating managed care in this state," Maxwell said.

Their joint legislative committee was formed in June to review the industry and consider a coordinated legislative plan to deal with the growing list of demands for legislative regulation.

Lanis Hicks, a M.U. associate professor of health services management, told the committee Wednesday that problems arise from the underlying philosophy of managed care operations.

"Rather than trying to manage the health of a population, current HMOs and managed care operations are built around the current model of insurance companies, which are based upon exclusion," she said.

One issue that has struck a chord with the committee was the quality and availability of emergency care. Several people last month told the committee that their HMO had told them not to go to the emergency room for treatment of fevers and broken bones. Witnesses testified that their HMOs defined those kind of problems as non-emergencies that could be handled by their primary-care physicians.

Maxwell said HMOs and other managed care operations shouldn't be in the business of telling people what was an emergency and what wasn't.

"A broken bone is an emergency and you ought to go to the emergency room," he said. "If they (the patient) reasonably believe that it is an emergency, then it should be considered an emergency."

As an example, Harlan, said for some, the symptoms of a heart attack are very similar to those associated with heart burn.

"And then, if it looked like a heart attack and it turned out to be heart burn, they (the HMOs) don't pay," he said. Hospital officials and doctors who testified before the committee last month said it often the hospital that absorbs the cost of the treatment.

Maxwell said the legislature could require HMOs to specifically outline what emergency services are covered by their plans.

Rep. James Foley, D-St. Louis County, said he heard that people were being turned away from emergency rooms because their hospitals were not part of their health plans.

"If you have a child and that child is sick, then you don't care where you go," Foley said.

Insurance Department Director Jay Angoff and other officials told the committee that managed care, if done correctly, was the best option, offering lower cost and better quality.

Maxwell said he also expected some recommendation from the committee to deal with allegations that managed care operations have imposed gag orders to limit what a doctor can tell the patient about options not approved by the health plan.

"Why in the world would you need that in Missouri?" he said. "That is a case of the HMO's (review panel) practicing medicine, not the patient's doctor, and some of those doctors might not be licensed to practice in Missouri."

While HMOs aren't the answer to all the health care problems, they have allowed more people to gain access to basic health care, Hicks said.

That differs sharply with the theme that was heard last month when over 150 people told the committee just the opposite: that managed care was leading to reduced health coverage for most.

Nearly 2 million people use some form of managed care in the state.

Originally, Maxwell and Harlan had said they planned to wrap up the public hearings this week but several unanswered questions prompted the chairmen to extend the hearings into next week.

Several people were asked back by the committee including Angoff and Donna Checkett, director of the state's Medical Services Division that oversees the state's Medicaid program.

Harlan and Maxwell said they are hoping to present their recommendations to the governor's office and legislative leaders in October.