Managing Managed Care Lawmakers Seek Greater Control Over How HMOs Do Business In Massachusetts

These aren’t the easiest of times for health maintenance organizations in Massachusetts.
Besieged on one side by legislators eager to grant patients the right to sue their HMOs, they’re busy on the other side trying to remain fiscally viable in an increasingly complex medical landscape.

After two years of often dramatic changes in the operation and oversight of the state’s HMOs, the challenge remains to offer patients adequate coverage and services while maintaining enough independence to forge a successful niche in what has been an industry in upheaval in Western Mass.

That’s not easy, said Peter Straley, president of Springfield-based Health New England — especially as the average age of the population rises, patients use more services, and legislators mandate that more and more of these services are covered by insurance.

“As technology progresses rapidly with the introduction of new treatments and new drugs, we find that we can take care of really, really sick people better, so they can recover and have better lives — but this all comes with an immense price tag,” Straley said.

The goal in the coming year, he said, is no different than in past years: to provide affordable health care coverage at a time when business and industry in general are not exactly expanding. The challenges for health plans, however, certainly are.

Clamoring for Coverage

As always, HMOs must deal with the flood of bills proposing coverage for treatments that don’t currently fall under the umbrella of insurance. Rep. Cele Hahn, R-Westfield, says the House Insurance Committee, of which she is a member, handles some 500 bills each year, many seeking to push HMOs to expand their coverage.

“There are a lot of bills, but I doubt many will make it through the year successfully,” Hahn said. Among the ones with a chance in 2002, she said, are bills to mandate coverage for artificial limbs, wigs for people with alopecia, and treatment of ectodermal displasia, a rare skin disease that afflicts children — about 70 right now in Massachusetts — and is characterized by tooth and hair loss. While those bills and some others might see the light of day, Hahn said, legislators might be less apt than at other times to pass large numbers of new requirements.

“I think we’ve forced HMOs to pay for enough extra items in recent years, not the least of which was mandated coverage for mental health services,” she said.

Straley said he recognizes that HMOs, as part of a highly regulated business sector, are prone to these forced changes, and for good reason — they are responsible for guarding their members’ health.

“It is completely understandable that people will turn to their local representatives and ask them for legislation that will cover this benefit or that benefit. We can all relate to that,” he said.

On the flip side, however, what the state’s health industry needs most is a discussion of how the entire health insurance system is constructed — especially if the cost of health care continues to rise at double-digit rates.

“It would be great if we could cover everything, if there was one standard for everyone, and it didn’t cost anything — but it does cost,” he said. “This is a societal issue. We have to make choices that offer the greatest good for the greatest number of people. We don’t have unlimited resources.”

Some proposals get more attention than others, and that goes for Senate Bill 805, which would require insurers to cover contraceptive drugs and services and hormone replacement therapy for women.

The bill, sponsored by Sen. Dianne Wilkerson, D-Boston, sailed through the Senate in October by a 33-0 vote, and it is now in the House of Representatives Ways and Means Committee with no timeline in place to bring it out.

Each legislative action has consequences, Straley noted. For instance, since in-vitro fertilization has become a covered procedure, the rate of multiple births has risen.

Twin and triplet babies tend to be smaller than those of single births, meaning more medical care — and cost — is required. “Part of the problem with legislating coverage is all of the other impacts it has,” he said.

To Sue or Not to Sue?

Speaking of an action with consequences for the industry, health plan administrators still await word on Senate Bill 1813, which would allow a patient to sue an HMO if it denies a covered, doctor-recommended treatment and the patient is harmed as a result.

The bill has been in the Senate Ways and Means Committee since early in 2001, and its sponsor, Sen. Mark Montigny, D-New Bedford, and other proponents hope it may be brought out sometime in 2002.

“This is not a bill that allows people to sue their HMO for denying something that is not covered because it’s a mean thing to do, or for denying a purely cosmetic treatment that isn’t medically necessary,” said Tom Dehner, deputy general council for the Ways and Means Committee. “For insurers that are looking out for their own interests and not the interests of the patients, this bill allows them to be sued when they make a medical decision about a treatment that is warranted or medically necessary.

“We’re still very hopeful that the bill will be reported out of this committee fairly early in the next session,” he said.
Insurers generally oppose the bill, claiming that health plans don’t make treatment decisions and diagnose patients in the same way doctors do; they simply arrange for and pay for medical care.

Dehner disputed that notion, saying that health plans have nothing to fear from the bill if they aren’t making medical decisions that affect the quality of a patient’s care. “It’s only intended to reach that situation where an insurer makes a medical determination that amounts to malpractice in the medical definition of the term,” he said.

Montigny’s bill would establish an independent malpractice tribunal to screen cases, and damages would be limited. He has also stressed that a patient would have to prove not only a poor decision by the HMO, but that the decision directly caused damage.

The bill actually dates to 2000, when the majority of state senators supported it, but the House did not back it, and it was sacrificed in order to push through sweeping HMO reform legislation that did have the backing of both houses. Opponents of Montigny’s bill note that the 2000 legislation does include an expanded grievance and appeals system whereby a doctor may be appointed to conduct an external review of the complaint.

The Mass. Assoc. of Health Plans, formerly the Mass. Assoc. of HMOs, maintains that the proposed bill would only clog the courts without actually improving health care and would also force HMOs to become even more involved in day-to-day medical practice. Because health plans would need to better supervise its physicians, the argument goes, the bill would lead to fewer doctors to choose from, defensive medical practices, discouragement of promising treatment innovations, and an overall lowering of health care quality.

Heal Thyself

The cost of legal expenses driven by such a bill worries HMOs, which already are looking to a future of more prescriptions, more treatments, and more mandated coverage.

That’s why prevention and self-maintenance are important, and Straley said Health New England strives to teach people how to manage their own care, through education outreaches in areas such as asthma treatment and diabetes care. The economic benefits of preventive efforts will help to offset the growing costs of new technology and an aging population, he said.

“Imagine how many fewer dollars would be spent on health care if we all just took better care of ourselves,” he said. “Health plans can definitely help with that.”

Nothing, however, is likely to prevent a continued flood of legislation, complicated new procedures, and longer lives throughout the Commonwealth. For HMOs that want to survive in such an environment, the dual task of taking care of patients and taking care of business has never been more difficult.