[Congressional Record Volume 142, Number 134 (Wednesday, September 25, 1996)]
[Extensions of Remarks]
[Page E1695]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




          THE MANAGED CARE ORIENTATION AND MEDICAL PROFILE ACT

                                 ______
                                 

                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                      Tuesday, September 24, 1996

  Mr. STARK. Mr. Speaker, I am pleased to introduce ``The Managed Care 
Orientation and Medical Profile Act.''
  For the past decade, the Medicare and Medicaid programs have been 
joining the national movement to managed care. Medicare enrollment in 
capitated Health Maintenance Organizations (HMOs) jumped from 441,000 
members in 1985 to almost 3.5 million beneficiaries as of March 1996. 
Medicaid enrollment in managed care has been more dramatic as States 
have received Federal waivers to enroll almost all of their Medicaid 
recipients in HMOs.
  The growth in managed care is largely due to the aggressive marketing 
practices of managed care plans. HMOs place financial incentives on 
door-to-door agents to enroll as many new members as the plans can 
handle. Medicaid HMOs even stake out food stamp offices targeting 
would-be enrollees with free gifts and high pressure tactics.
  Unfortunately, these practices put some of our most vulnerable 
populations at severe risk. Consumer advocates have reported that 
Medicare and Medicaid beneficiaries are often enrolled without 
understanding what they are signing. Some unscrupulous health plans 
even prey on non-English speakers or the mentally handicapped. As a 
result, many new enrollees are left clueless as to how their health 
plan works or how to access care while the HMOs begin receiving 
payments from the government for care they are not providing.
  Once an individual is enrolled, Medicare sends the HMO somewhere 
between $300 and $700 per month (depending on the region of the nation) 
to maintain the health of that person and to treat them when they are 
sick. In many cases--perhaps most cases--Medicare can spend thousands 
and thousands of dollars on behalf of an enrollee before that person 
ever visits the HMO. In the meantime, the health of the enrollee can 
actually be deteriorating and more serious problems can be developing.
  The legislation I propose today address this problem by making HMOs 
more accountable for the lives they enroll. In order to enroll new 
patients, HMOs would have to fulfill the following requirements before 
payment begins:
  First, conduct an orientation meeting with the new enrollees 
introducing them to managed care and clarifying where to access care, 
which benefits are covered, and all payment structures including 
deductibles and copayments.
  Second, conduct a preventive screening as defined by the Secretary 
and an immunization assessment for children.
  Managed care claims to be effective because it works with the patient 
to ``manage'' health and prevent illness. When the government is paying 
the bill, we ought to demand that plans live up to this promise by 
mandating the orientation and medical profile before their payment 
begins. In the medical profiling encounter, the HMO can begin to work 
with the enrollee on issues such as diabetes, lack of immunization, 
obesity, smoking, alcoholism, pre-cancerous skin conditions, high blood 
pressure--the whole range of potential health problems that a good HMO 
should know about their enrollees and be working to improve.
  The August 1996 issue of New York's United Hospital Fund newsletter 
``PolicyLine'' shows why the idea of requiring a meeting and work-up 
before we start paying HMOs makes a great deal of sense:

       Even if specifically required to assume certain public 
     health responsibilities, however, managed care plans may not 
     yet have the experience or systems to fulfill their 
     responsibilities, as experienced in Wisconsin demonstrates. 
     Five years into its managed care initiative, Milwaukee 
     experienced a measles epidemic. According to Paul Nannis, 
     Milwaukee Commissioner of Health, the city had 1,100 cases of 
     measles in 1990, mostly among disadvantaged preschool-aged 
     children. Eighty-three percent of these children were in 
     HMOs; three of them died. Subsequent analysis revealed that 
     of all the preschoolers enrolled in the HMOs, two-thirds were 
     not appropriately immunized. In the wake of this crisis, the 
     department of health provided 20,000 shots in a ten-week 
     period, 55 percent of them to children enrolled in HMOs.
       In analyzing the events that led to the crisis, Mr. Nannis 
     said that the independent practice associations that were 
     operating as managed care organizations had not fundamentally 
     altered the way they delivered primary care services. Simply 
     renaming the existing system managed care and changing the 
     reimbursement process for physicians who continue to practice 
     medicine the same way they always have done does not 
     magically manage anybody's care, said Mr. Nannis.

  While the Milwaukee example refers to a Medicaid managed care type 
program, I believe its lessons apply more broadly. As the article 
continues, Mr. Nannis is quoted as saying

       * * * public health agencies [read: HCFA] and HMOs need to 
     be at the same table before initiatives start. Managed care 
     plans should be expected to provide uniform data on enrollees 
     including prevalence and cause of mortality, morbidity, and 
     disability; timing and frequency of immunizations; and 
     effectiveness of interventions.

  HMOs and managed care can be a wonderful thing for the health of the 
American people--but only if people know how to use their HMO and only 
if their HMO works with them to prevent the minor problems of today 
from becoming the medical catastrophes of tomorrow.

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