HMOs Failing State Standards Essay, Research Paper

New Yorkers may be covered by one of the nation’s most comprehensive health consumer protection laws–but insurers routinely flout it, according to a report released yesterday by New York City Public Advocate Mark Green.

Posing as prospective clients, Green’s investigators called 12 of the region’s health maintenance organizations, including some of the largest on Long Island and in Queens, to get information about their complaint records, lists of covered prescription drugs and medical procedures, and policies on confidentiality and experimental treatments. Although New York’s new managed care bill of rights requires health plans to provide the information to both members and potential members, all of the HMOs flunked the test most of the time, with representatives either unwilling or unable to answer the questions.

“Five out of six times the HMOs refused to tell one of our callers whether a drug

was covered by the HMO,” Green said. “Not to know whether the HMO you might join will cover a drug you use monthly is like a computer store refusing to tell you the memory of the computer–or an auto dealership refusing to give you the miles-per-gallon of the Pontiac.” “Our callers got extremely frustrated, and their health wasn’t even at risk,” Greensaid. The survey was conducted in July and August, just months after the New York law went into effect in April. Kevin McGrath–a spokesman for Wellcare, the small plan that had the worst score–said that although he hasn’t seen the full report, he is “suspicious” of the survey’s methodology because the results were so extreme. “From the results, it looks to me that the survey may be flawed,” he said. “The results are hard to believe.” [CURE Comment: Not to MCL subscribers, Kevin.]

Even Cigna HealthCare of New York, which scored highest on a point system devised by Green, complied with the law only one-third of the time, according to the report. Other top performers were NYLCare Health Plans of New York, which complied 15 percent of the time, and United Healthcare and Oxford, which both complied 14 percent of the time. Prudential HealthCare, MagnaCare/MagnaHealth and WellCare ranked at the bottom of the list, complying less than 5 percent of the time, Green’s office said. Health Insurance Plan of Greater New York, Aetna/US Healthcare and Empire Blue Cross and Blue Shield ranked in the middle, complying 20 percent, 16 percent and 13 percent of the time, respectively. Physicians Health Services Inc. and Healthsource Inc. both complied 14 percent of the time.Bob Hinckley, a spokesman for the state Department of Health, said the department has cited two plans–Aetna/US Healthcare and Oxford-for violations, but said the plans were not fined. [CURE Comment: That's really getting their attention, Bob.] Officials from managed care plans contacted yesterday refused to discuss the survey, saying they had not yet read the report. Amy Nacinovich, a spokeswoman for the HMO Council and Conference, an Albany-based trade association, also declined comment. According to the report, Green’s investigators often faced long waits on the phone only to be told they had to submit their questions in writing, and were promised information would be mailed to them that never was. In some cases, callers were given inaccurate information, or got contradictory answers when calling the same HMO more than once. New York’s Managed Care Bill of Rights is one of the nation’s most comprehensive. Among other provisions, it requires disclosure of a wide range of information, from the drugs the plan will pay for to the criteria used to determine which medical procedures are covered. Green’s report is based on a monthlong survey done by his office, and consists of responses to 132 telephone calls and 216 requests for w

Doctors throughout the nation are claiming that health maintenance organizations (HMOs) limit their ability to speak freely with patients about treatment options and payment policies. Many doctors say that these restrictions interfere with their ethical and legal duty to provide patients with important information concerning the benefits, risks and costs of various treatments. HMOs say that the restrictions, called confidentiality clauses, are there to protect trade secrets and proprietary information. They want doctors to discuss their concerns about payment and treatment policies with doctors and physician managers in the health plan, rather than with patients. Critics argue that patients need to understand the financial arrangements and that the clauses keep doctors from becoming advocates for their patients. Doctors who want to recommend a treatment not covered by the HMO in which a patient is enrolled, or refer patients to specialists not affiliated with the plan,are limited by a confidentiality clause. Doctors who adhere to such restrictions may be sued for malpractice. Doctors in New York have filed a lawsuit challenging a confidentiality clause, illustrating the tension between them and HMOs as health plans try to monitor and regulate the doctors’ behavior. HMOs say the clause is a way to prevent doctors from sharing their frustration with patients. Opponents say the HMOs use financial rewards and penalties to force doctors to limit care and then try to prevent them from speaking out.

Source: (Newsday)

http://www.familiesusa.org/farisk.html

http://www.harp.org/tiopi.txt

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