HMOs...Here We Go, Again

It ain't over 'til it's over.

Did Yogi Berra say that? About what?

Well, it could have been the HMO legislation, or the patients bill of rights...which didn't get through the legislature last year and we're tackling it again this year.

The Senate, you see, approved one version of managed care reform. The House voted for a different version. And now, again I might add, a conference committee has been named to iron out the differences.

I was a member of that conference committee last year. And, I'm a member of the new conference committee this year.

Negotiations can't really start until the Budget for Fiscal Year 2000 is approved, mainly because the House and Senate Chairs of Ways and Means are on both the budget conference committee and the HMO conference committee. So, if you're waiting for immediate changes, it could be a long wait.

I think the House bill goes a long way toward improving the care you get from your managed care provider. The care you deserve.

For starters, emergency room visits would be covered under the "prudent layperson" standard. If you think you're having a heart attack, for example, and go to the emergency room only to find out it's not a heart attack, your visit would be covered.

An appeals process would be put in place. If your HMO denies you certain coverage or services, you could appeal their decision to an external review board.

Women in their third trimester of pregnancy, as well as terminally ill people, would be able to continue seeing physicians who opt out of the HMO system. And women could consider their obstetricians and gynecologists as their primary care doctors.

Doctors and hospitals should be happy with the legislation, as well. it would make managed care organizations responsible for paying undisputed claims within 60 days of receipt and add interest charges after 60 days.

Further, HMOs would not be allowed to have plans that would give doctors incentives for reducing or limiting necessary medical care. And, the House versions would prohibit members from suing their HMOs.

HMOs would be given "report cards," an evaluation of services and comparison of plans, so consumers can make informed decisions about which insurance to buy.

There's more. But, basically, the House bill would provide new protections for patients yet keep the health insurance policies affordable. We can't push the rates up so high that no one can afford to buy insurance.

I've spent hours this year studying the issue, and meeting with members of the Massachusetts Medical Society and Massachusetts Association of HMOs. Both groups feel that the House bill is a good compromise, for patients, doctors and insurers. And business groups like Associated Industries of Massachusetts prefer the House version.

But, as I said in the beginning, it ain't over until it's over. And it's only just begun.

All materials copyright 1997 - 2014