It Ain't Over 'til It's Over ... HMO Reform

The middle of this week I thought we had successfully negotiated a House and Senate agreement on managed care reform. In fact we all had. We were wrong.

I say "we" because there were six of us, and we had been negotiating the legislation for almost three years, over two sessions of the state legislature. Three Representatives (Ways and Means Chair Paul Haley of Weymouth, Health Care Chair Harriett Chandler of Worcester, and me) and three Senators (Ways and Means Chair Mark Montigny, Richard Moore of Uxbridge, and Henri Rauschenbach of the Cape) were appointed to iron out the differences between Senate and House versions of HMO reform legislation.

The goal: to piece together changes that would strike a balance between health care and cost containment, while trying to please hospitals, physicians, the HMOs themselves, and consumers. Most important were cost, access and quality of care.

Six months ago, I didn't think we'd accomplish the job. But, after long discussions and arguments, hundreds of hours of staff work, and a lot of give and take, the committee thought we had succeeded.

The details are many, but here are some of the things that are important to meand to you, if you have an HMO.

Patients should have more access to relevant information about fees, coverage and the appeal process to contest denial of services. And that process is, perhaps most importantly, set up for both internal and external reviews-a way to argue your case, if you are denied services, before the HMO itself and then before a nonpartial board.

Terminally ill patients and women in their last stages of pregnancy should be allowed to continue to see the same physicians. And women should be allowed to use their OB/GYN as their primary care physician, instead of waiting for referrals. Patients with chronic diseases should be able to obtain standing referrals to specialists. Pediatricians for kids, too.

We want the "prudent layperson" language for emergency room services. If you go to an emergency room, but the situation is not an emergency, your HMO should still pay if a "prudent layperson" might have thought an illness (say, heartburn) was serious (perhaps a heart attack) even if it wasn't.

Physicians must be allowed to make more decisions, without worrying about utilization review or cost-saving medical denials. Basically, that means they can make treatment decisions without interference from a managed care organization.

We must mandate prompt payment of completed provider claims. The HMOs should have to pay hospitals, physicians, and other providers on a timely basis.

There were a lot of things that we probably won't do. Just one example, allow people to sue their HMOs.

But there's still more work to do. Yet to be decided is if the legislature should also establish a commission to evaluate and analyze a so-called universal health care program for Bay Staters. Also, a ban, or moratorium, on non-profit hospitals and HMOs converting to for-profit. I don't care for any of them, frankly.

No matter what we do, not everyone will be happy-some hospitals, insurers and consumer groups are already complaining that the bill goes too far, or, conversely, not far enough. But, the Committee thinks that we're able to come to an agreement that best meets the needs of all groups and individuals, while remembering cost, quality and access.

Of course, it isn't over yet. More conference committee meetings before the agreement is reached. Then, the House and Senate have to vote on the Conference Committee Report. If approved, it will go to the Governor for his approval.

And, in case we don't get it all in one package, backers of a ballot question calling for universal health care and a patients bill of rights this week filed almost 14,000 certified signatures to put the matter on the ballot this fall. So you'll have your chance, too.

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