[Congressional Record Volume 144, Number 20 (Wednesday, March 4, 1998)]
[Extensions of Remarks]
[Pages E287-E288]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




      MANAGED CARE CONSUMER PROTECTIONS: WHY COSTS WILL BE LIMITED

                                 ______
                                 

                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                        Wednesday, March 4, 1998

  Mr. STARK. Mr. Speaker, the opponents of managed care consumer 
protections constantly say that the cost of the reforms will 
substantially drive up costs, and therefore cause employers to drop 
insurance coverage for their workers.
  Some of their cost estimates are laughable. Remember the old Western, 
``Have Gun, Will Travel?'' There is a whole industry in Washington of 
Ph'Ds who serve the same bounty hunter role. ``Have Ph'D; Will Produce 
the Study Results YOU Want.'' Or as the old vaudeville joke goes, ``If 
the man wants a green suit, turn on the green light.''
  One reason the studies are silly is that the States are already 
requiring, for the roughly 50% of plans that they can regulate, that 
managed care plans comply with the type of reforms we are proposing. 
Another reason is that the managed care trade association, AAHP, 
already requires as a condition of membership that a plan comply with 
many of these standards. The question arises, why should there be much 
extra cost if the plans are already complying with their trade 
association's quality standards?
  Using data from Blue Cross Blue Shield, my staff has compiled the 
following matrix of State actions. Clearly, the passage of Federal 
legislation will not be asking the managed care plans to deal with 
issues they are not already dealing with on a wide scale.

                     State Consumer Protection Laws

       Attached is a preliminary summary of States' consumer 
     protection laws. This information, taken from the Blue Cross/
     Blue Shield Association's 1997 Survey of Health Plans, 
     indicates that all but four states have enacted at least one 
     of the managed care quality protections listed in the 
     President's Consumer Bill of Rights. In addition:
       Thirty-nine (39) states have enacted laws prohibiting ``gag 
     clauses'' in provider contracts.
       Twenty-nine (29) states have enacted laws allowing direct 
     access to specialists without prior approval from the plan's 
     primary care physician. These laws apply primarily to OB-
     GYN's, but a few also refer to chiropractors, dermatologists, 
     and other specialists. Another five (5) states are expected 
     to propose direct access to specialists in 1998.
       Twenty-six (26) states have enacted laws requiring payment 
     for certain care delivered in an emergency room. Almost half 
     (12) of these states also impose a ``prudent layperson'' 
     standard. Another nine (9) states are expected to introduce 
     legislation with the ``prudent layperson'' standard in 1998.
       Twelve (12) states have external grievance review laws that 
     require health plans to allow enrollees to appeal coverage or 
     claims denials to an outside medical expert of panel, if 
     dissatisfied with the outcome of the plan's internal appeals 
     process. Another 12 states are expected to enact mandatory 
     external grievance review laws in 1998.
       Sixteen (16) states (CA, DE, FL, HI, IA, ID, IL, IN, KY, 
     MD, ND, OK, PA, SC, TN, and WA) are expected to propose a 
     framework of quality standards for managed care plans in 
     1998.

                                                      STATES' CONSUMER PROTECTION LAWS (AS OF 1997)                                                     
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                               Choice of                  Prohibition                                                   
                    State                          Info        plans and   Access to ER     on gag         Respect and     Confidentiality   Complaints 
                                                disclosure    providers*    services\1\     clauses    nondiscrimination#                     appeals** 
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama......................................  ............            X   ............  ............  ..................  ...............  ............
Alaska.......................................  ............  ............  ............  ............  ..................  ...............  ............
Arizona......................................            X   ............            X             X   ..................  ...............            X 
Arkansas.....................................  ............            X             X   ............  ..................  ...............  ............
California...................................            X            X*             X             X   ..................  ...............            X 
Colorado.....................................  ............           X*             X             X   ..................  ...............  ............
Connecticut..................................  ............            X             X             X   ..................  ...............            X 
Delaware.....................................  ............            X        Xcaret             X   ..................  ...............          X** 
District of Columbia.........................  ............  ............       Xcaret             X   ..................  ...............          X** 
Florida......................................            X             X             X             X   ..................  ...............            X 
Georgia......................................  ............            X             X             X   ..................  ...............          X** 
Hawaii.......................................  ............  ............  ............  ............  ..................  ...............          X** 
Idaho........................................            X             X             X             X   ..................  ...............  ............
Illinois.....................................  ............            X        Xcaret   ............  ..................  ...............  ............
Indiana......................................  ............            X        Xcaret             X   ..................  ...............  ............
Iowa.........................................  ............  ............  ............  ............  ..................  ...............  ............
Kansas.......................................  ............            X             X             X   ..................  ...............  ............
Kentucky.....................................  ............            X        Xcaret   ............  ..................  ...............  ............
Louisiana....................................  ............            X             X             X   ..................  ...............  ............
Maine........................................  ............            X   ............            X   ..................  ...............  ............
Maryland.....................................  ............            X             X             X   ..................  ...............          X** 
Massachusetts................................  ............            X   ............            X   ..................  ...............  ............
Michigan.....................................  ............  ............            X             X   ..................  ...............  ............
Minnesota....................................  ............            X   ............            X   ..................  ...............  ............
Mississippi..................................  ............            X        Xcaret   ............  ..................  ...............          X** 

[[Page E288]]

                                                                                                                                                        
Missouri.....................................  ............            X             X             X   ..................  ...............            X 
Montana......................................  ............            X   ............            X                X      ...............  ............
Nebraska.....................................  ............           X*             X             X   ..................  ...............  ............
Nevada.......................................  ............            X             X             X   ..................  ...............  ............
New Hampshire................................  ............            X             X             X   ..................  ...............          X** 
New Jersey...................................  ............            X             X             X   ..................  ...............            X 
New Mexico...................................  ............            X   ............            X                X      ...............  ............
New York.....................................  ............            X             X             X   ..................  ...............          X** 
North Carolina...............................  ............            X             X             X   ..................  ...............            X 
North Dakota.................................  ............  ............  ............            X   ..................  ...............          X** 
Ohio.........................................  ............  ............            X             X   ..................  ...............            X 
Oklahoma.....................................  ............           X*             X             X   ..................  ...............          X** 
Oregon.......................................  ............            X             X             X   ..................  ...............  ............
Pennsylvania.................................  ............            X        Xcaret             X   ..................  ...............          X** 
Rhode Island.................................  ............            X        Xcaret             X                X      ...............            X 
South Carolina...............................  ............            X        Xcaret   ............  ..................  ...............  ............
South Dakota.................................  ............  ............  ............  ............  ..................  ...............  ............
Tennessee....................................  ............           X*             X             X   ..................  ...............            X 
Texas........................................  ............            X             X             X   ..................  ...............            X 
Utah.........................................  ............            X   ............            X                X      ...............  ............
Vermont......................................            X            X*   ............            X   ..................  ...............            X 
Virginia.....................................  ............            X             X             X   ..................  ...............  ............
Washington...................................  ............            X             X             X   ..................  ...............          X** 
West Virginia................................  ............  ............  ............  ............               X      ...............  ............
Wisconsin....................................  ............  ............  ............  ............  ..................  ...............  ............
                                              ----------------------------------------------------------------------------------------------------------
Wyoming......................................  ............  ............  ............            X   ..................  ...............  ............
  Total......................................            5            34            35            39                5                  0            24  
--------------------------------------------------------------------------------------------------------------------------------------------------------
*Twenty-nine (29) states have laws that allow direct access to a specialist without prior referral from the primary care physician. These apply         
  primarily to OB-GYNs, but also can refer to chiropractors and dermatologists. Another 5 states (*) are expected to propose self-referral to           
  specialists in 1998.                                                                                                                                  
caretTwenty-six (26) states have enacted laws requiring payment for certain care delivered in the emergency room. Twelve (12) of these states also      
  impose a ``prudent layperson'' standard. Another nine (9) states (caret) are expected to introduce this legislation in 1998.                          
#Five states prohibit discriminatory practices (e.g., denying/canceling coverage, higher premium) against victims of domestic abuse.                    
**Twelve (12) states have external grievance review laws that require health plans to allow enrollees to appeal coverage or claims denials to outside   
  medical expert or panel, if dissatisfied with outcome of plan's internal appeals process. Another 12 states (**) are expected to enact mandatory      
  external grievance review laws in 1998.                                                                                                               
                                                                                                                                                        
 Source: Blue Cross Blue Shield Association 1997 Survey of Plans.                                                                                       




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