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Patient Choice Stressed in HMO Bill

State Capital Bureau

February 07, 1995

JEFFERSON CITY _ Preserving patient choice _ the issue that helped scuttle Pres. Bill Clinton's health care plan last year _ is the central goal of one of the major health-care bills before Missouri's legislature.

The proposal deals with the rapidly growing sector of managed care plans _ or HMOs.

Touted by proponents as an HMO consumer-protection bill, the measure targets patients whose doctors have been dropped by their managed care plans, forcing them to find new physicians.

But critics say it's more a doctor-protection, rather than consumer-protection proposal.

Deborah Jantsch, an obstetrician/gynecologist from Kansas City, told the Senate General Laws Committee of her experience with patients who have come to her in such situations.

"They said, `I have a doctor. I have gone to my doctor for the last 14 years. That doctor delivered both my children, but is no longer on my provider panel. And now I have to come to you.' Can you imagine starting a relationship on this kind of footing?"

The Patient Fairness Act, sponsored by Sen. John Scott, D-St. Louis, attempts to cut down on these situations by prohibiting HMOs from terminating physicians' contracts without cause.

The bill also would require HMOs to accept applications from all physicians in their geographic area and provide applicants with the reasons used if they were rejected.

Insurers and managed care companies claim the costs involved in these requirements outweigh any benefits to consumers.

The required documentation would be "an extremely expensive administrative process," said Randy Scherr, a lobbyist for Prudential Insurance Co.

"What about a hospital that has 40 doctors on staff, and that's all they need?" Scherr said. "They could be required with this bill to take applications from 800 or 1,000 physicians, and then go through the process of denial, on the record, for every one of them. There is no advantage to anyone to do that; it's just more cost."

But William Crowley, a retired neurologist and chair of an ad-hoc medical group that drafted the bill, said that what the bill would require of HMOs is that they publish their criteria for accepting physicians.

"It would just be a few written pages," Crowley said. "Since the companies already have this information, it's a simple question of making it public."

But if an individual physician asks why he or she were not accepted, the HMO should provide those reasons, Crowley said.

Crowley agreed that insurance companies would pass on to consumers any costs involved in implementing the bill's requirements, but said those costs would not be significant.

"The insurance companies and managed care companies are just that _ companies; they won't operate at a loss," Crowley said. "But I don't agree with the premise that (the requirements) would be costly."

The bill's sponsor said the end result of the measure might not be to reduce health-care costs, but the bill would not increase costs, either.

"How much paperwork can it be," Scott said. "I don't think it will increase costs, not one nickel."

Another section of the bill would require managed care plans to be explained to enrollees in easily understood terms.

"Patients are entitled to know the details of the plans they're buying," Crowley said. "Right now, insurance companies have a way of making plans so hard to understand that people don't know what they've bought."

Scott said his committee expects to vote on the bill later this month (February).