• 21st Century Issues •
Managed care backlash may boost patient care
Megamergers, stricter regulations, rising costs, course corrections and better care -- managed care can look forward to all that in the early 2000s.
"The backlash from physicians, patients and the media; state laws; and court rulings are pushing in on managed care," says Lee Sacks, M.D., of Oak Brook, Ill., chair of AAFP's Commission on Health Care Services.
Sacks foresees more consolidation, with regional plans in financial difficulty becoming the acquisition targets. "The large plans will come into a market and cookie-cutter it out," he says. "They use one claim system. It doesn't acknowledge differences among Chicago, Kansas City and New York, or among areas with large physician groups and those without."
The U.S. Congress is at loggerheads over its managed care legislation, with divergent House and Senate bills and slight chance Congress will send President Bill Clinton legislation he is willing to sign.
But states are clamping down on managed care (see chart).
States tighten reins on managed care
ISSUE ADDRESSED VIA LAWS OR REGULATIONS
Bans on gag clauses
Inpatient care after childbirth
Emergency care service mandate
Direct access to OB/Gyn - or - OB/Gyn as primary care provider
Prompt payment to providers
Any willing provider accepted in health plans
Definition of medical necessity
Standing referrals
Licensing of medical directors
Insurer liability
NUMBER OF STATES
48
42
38
37
35
22
22
22
19
3
Source: Health Policy Tracking Service, National Conference of State Legislatures, December 1999"We can't stand by and wait for the bipartisan bickering in Washington to end," says Mary Frank, M.D., of Rohnert Park, Calif., chair of the AAFP Commission on Legislation and Governmental Affairs. "Our governor signed legislation in 1999 that accomplishes a lot of reforms the AAFP has been working for at the federal level. The law requires HMOs to cover breast exams, breast cancer treatment and treatment for some mental illnesses and to cover contraceptives as prescription drugs. Maybe states can set the model for federal legislation."
HMOs have begun dropping Medicare patients in areas of lower reimbursement. "Some of that's politics," says Sacks. "They sent a message to Congress." 1999 adjustments to the Balanced Budget Act of 1997 included an upswing in HMO Medicare reimbursements in areas not covered by Medicare+Choice.
Faced with widespread managed care backlash, the industry apologized in late November. The American Association of Health Plans sent a memo to health plan executives saying industry practices helped precipitate the criticism and some practices may need to be changed.
A few weeks earlier, UnitedHealth Group freed providers from needing prior approvals for many tests and hospitalizations.
"There'll be a swing back to a greater focus on patients," says Sacks. "And besides, most physicians acknowledge managed care has improved health care tremendously. For example, nobody did any review in my office until managed care started auditing, and our documentation has improved, as well as our cancer screening."
Even with improvements in operations, though, pressure on physicians is likely to increase because of hikes in health care costs. "Employers will look to managed care to help lower the rate of increase in health care costs. Once again, physicians will be caught in the middle," says Sacks.
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
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