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Lamakers propose managed care changes

November 14, 1996
By: Andy Kravetz
State Capital Bureau

JEFFERSON CITY - Giving patients more decision-making power and creating a standard definition of medical emergency are among the recommendations of a legislative committee formed to reform the managed-care industry.

The Joint Interim committee on Managed Care's list of recommendations are the first step toward a final report to legislative leaders. Eventually some, if not all, of the recommendations will be introduced as legislation.

The recommendations released Wednesday range from elimination of "gag rules," which are clauses that don't allow doctors to fully advise a patient, to the inclusion of a layperson's definition of what should be treated in an emergency room.

Those aren't things the managed-care industry necessarily wants. More legislation usually means more regulation, which Mike Winter, lobbyist Missouri Managed Healthcare Association, said would not help.

"The impact of the recommendations that the Joint Committee adopted today will have no meaningful benefit to the quality of health care and it will increase the cost for the he consumer," Winter said.

Missouri has had explosive growth in manage care over the past few years. Nearly 2 million Missourians are covered by some form of managed care. Managed care companies control costs by closely monitoring how doctors treat their patients.

Experts predict that by 1988, 70 percent of Missourians will be involved with managed as their insurer.

Committee co-chairmen Rep. Tim Harlan, D-Columbia, and Sen. Joe Maxwell, D-Mexico, have both put accessibility to emergency care at the top of their list.

Harlan said he hopes a "prudent layperson's" definition of an emergency will reduce the chances that a person would not be covered if they went to an emergency room.

Currently, a health maintenance organization can retroactively decide not to pay for an emergency room visit if the condition turned out be a nonemergency. But Harlan said such thinking might discourage people from getting treatment.

He used the example of a person with heartburn. The symptoms are very similar to a heart attack, but under current regulations, an HMO or managed-care company could refuse to pay for a person's treatment if it turned out to be only heartburn.

"A decision on payment should depend on a person's symptoms when they arrive at the emergency room, not on the final diagnosis," Harlan said.

The managed-care industry opposes such a change, but agreed that one needs to be made.

Committee members also favored giving patients more power in choosing whether to see a specialist. In an HMO, authorization to see specialists is given by family doctors and other primary-care providers, who in turn have to check with the HMO to see if the plan will allow such visits.

In effect, an HMO can block patient's access to specialists such as dentists, chiropractors, obstetricians and gynecologists.

The committee wants to allow HMO users to see specialist who are part of the plan without having to go to their primary-care physician.

Sen. Betty Simms, R-St. Louis County, said self-referrals are important because it cuts down on the bureaucracy.

Patients also should be allowed to follow their doctor if that doctor leaves the health plan. Maxwell said HMOs and managed-care groups should allow a person to chose a new doctor or leave the plan.

"Treating a patient is more than just giving that person a pill. You have to understand the person and the community," said Rep. Mary Bland, R-Kansas City.

One of the biggest complaints of consumer groups have been complaining about is the immunity that HMOs have against medical malpractice claims. They said if an HMO will not approve a certain treatment for a patient, they are practicing medicine and should be liable in the lack of treatment results in further harm to the patient.

Committee members weren't exactly sure how to remove the immunity from the state codes, but they were adamant in their stance to remove the clause.

A final draft of the recommendation is expected to be released next week. The committee will then assign legislative priorities to items that they feel are of greater importance.