Managed Care Reform

The American Academy of Family Physicians (AAFP) supports managed care reform that ensures patients receive access to high-quality health care, clear information, and fair treatment from their health plans. The AAFP believes managed care organizations (MCOs) should protect the primary care physician's ability to act as the patient's advocate.

Below are provisions that the AAFP believes are essential to include when advocating for comprehensive managed care reform:

The AAFP supports:

  • A requirement that MCOs promote, measure, and maintain care quality improvements in comprehensive managed care programs, consistent with AAFP policy on “Performance Measures Criteria;”
  • A requirement that MCOs provide physicians with timely and actionable data on quality and costs, especially if the physician is responsible for the total cost of care for their patients;
  • A requirement that MCOs limit prior authorization and provide a streamlined prior authorization process that is efficient for patients and their physicians; the process should not limit physicians’ ability to prescribe or refer based on their specialty;
  • A requirement that information be provided before and at the time of enrollment to all plan enrollees in a uniform and easy-to-understand format; the information should include covered and excluded benefits, out-of-pocket expenses (i.e., deductibles, co-pays, and co-insurance) in providers, experimental benefits, and other important plan provisions;
  • A requirement that MCOs have just and equitable appeals process in place enabling meaningful and prompt access and providing timely resolutions for patients and their physicians;
  • A requirement that MCOs utilize a prudent layperson standard enabling patients to secure emergency care out of plan without prior authorization;
  • A requirement that MCOs honor the right of each physician and other health care providers to communicate freely with all patients;
  • A requirement that MCOs have a policy protecting physicians who advocate on behalf of their patients for needed medical benefits;
  • A requirement that MCOs have a policy ensuring "medical necessity" decisions will be made by physicians who have knowledge of a patient's particular medical history and circumstances;
  • A requirement that self-funded plans governed under the Employee Retirement Income Security Act of 1974 (ERISA) be held responsible for medical outcomes, as are other plans, within any given state;
  • The modification of ERISA to allow injured patients to seek recovery in federal court for improper coverage denials; and appropriate liability caps in federal court which will ensure MCOs recognize their responsibility to guarantee patients have timely access to needed medical care;
  • A requirement that MCOs have formularies that are consistent with AAFP policy on "Patient-Centered Formularies;"
  • The inclusion of family physicians in any definitions of women's and children's health care providers to ensure access to all qualified physicians;
  • Recognition of an accurate definition of primary care, consistent with the AAFP definitions of "Primary Care" and "Family Medicine;"
  • A requirement that MCOs must regularly update their provider directories to ensure patient coverage, while minimizing adminstrative burdens, and make it available to physicians and patients;
  • A requirement that MCOs must furnish physicians with a fee schedule showing what they will be paid for services, provided by that physician under the plan, before negotiating with the physician to become or continue as a healthcare provider under the MCO;
  • Recognition of the importance of advanced primary care functions consistent with the Joint Principles of the Patient-Centered Medical Home, as developed by the AAFP and others, by encouraging patients to visit primary care physicians as their usual source of care and providing payment that reflect the value primary care physicians bring to the health care system;
  • The use of a uniform provider contract template;
  • First dollar coverage for preventive services by MCOs, consistent with AAFP policy on "First Dollar Coverage for Preventive Care;" and
  • Adequacy of primary care and specialist networks (especially with regard to the number of available physicians and geographc availability).

(March 2001) (2017 COD)