Under Pressure, Health Plans Pledge Reforms

Facing the threat of federal reforms, health plans serving 100 million Americans pledged Tuesday to make it easier for patients to choose doctors, go to the emergency room and understand their benefits.

Women would be allowed to see a gynecologist or obstetrician whenever they want, for example, and all children would have the right to see a pediatrician, rather than be forced to have family practitioners as their primary-care doctors. Emergency room visits would be paid for by the health plan if a reasonable person--as opposed to a highly trained medical expert--would be likely to view the situation as an emergency.

The group also agreed to create an independent, uniform review process under which patients could appeal denials of tests, referrals and treatments. These independent review panels would be free to decide for themselves whether a treatment is medically necessary--and their decisions would be binding on the health plans.

The promised voluntary reforms, made by 22 health plans and two trade associations that collectively call themselves the Coalition for Affordable Quality Health Care, would also reduce administrative confusion, allowing patients to search for and choose doctors online, and simplifying the procedure by which a physician can join the network of a plan.

The actions by the health plans--which come in the midst of an escalating debate in Washington over a patients’ bill of rights--were clearly spurred in large part by politics. The same health plans and trade organizations have also spent tens of millions of dollars on advertising and lobbying campaigns to defeat federal and state reforms, and Tuesday’s announcement lacked key elements of most of those proposals: a mechanism for government enforcement and a means by which consumers can sue their insurers.

The pledges were prompted as well by a growing realization on the part of managed-care companies that their marketplace will slip away from them if something is not done to quell outrage and disaffection among consumers, doctors and hospitals.

“We’ve got a crisis of confidence in health care,” said Leonard Schaeffer, president of Thousand Oaks-based WellPoint Health Networks, which owns Blue Cross of California. “This is all about regaining trust. It’s acknowledging the concerns of physicians and members and taking steps to concrete action.”

“It hardly seems like a coincidence that this is coming in the middle of the patients’ right debate” in Congress, said Larry Levitt, chief health-care analyst for the nonprofit Kaiser Family Foundation. “But I also think it signals a real shift.”

If the health plans follow through, Levitt said, they will be embracing patient protections that they fought bitterly until very recently.

Some aspects of the plans’ promises, however--such as the commitment to allow women direct access to gynecological care and the promise that children can see pediatricians instead of family doctors--already exist for many patients under a combination of state laws and voluntary health plan actions.

For example, a recent study by the Kaiser Family Foundation determined that 67% of American women are allowed to use obstetricians and gynecologists as their primary-care physicians. Similarly, residents of more than 30 states have the right to an independent, outside review of any denial of care.

But in both situations, the rules vary from state to state, offering some consumers more protections than others. The 48 million Americans who receive their health care through employers that are self-insured, moreover, are excluded from such state protections by federal laws supported by the insurance industry. And some state laws are crumbling without federal protection, chipped away by industry lawsuits.

A coordinated effort by the health plans to make such protections uniform across the nation could go a long way toward solving some of the key problems of the managed-care era.

A particularly important, but lesser-known, area that would receive attention under the plans’ proposal is the cumbersome and duplicative red tape that doctors, hospitals and patients must learn to navigate in order to get proper care.

Under the direction of Jay Gellert, chief executive of Woodland Hills-based Foundation Health Systems, the companies have already hired consultants to develop a way to organize the benefits available to members into a simple, organized grid that would be shared by all managed-care plans. That way, consumers could easily read, on paper or online, the benefits, prescription drugs and physicians available on each plan, and choose accordingly.

The plans also hope to develop a single process for credentialing doctors so they don’t have to go through repeated applications and updates for each plan.

But these changes could be years in the making, according to Schaeffer. And they do not address an issue even closer to the hearts of doctors and hospitals than paperwork: money. In California and across the nation, providers are teetering on the verge of bankruptcy, and most blame health plans and the federal government for paying too little to cover the cost of care.

Further, say consumer advocates and others who support federal reform legislation, without the backing of the government, the pledges are unenforceable.

“They can promise you the moon, but if they don’t have any enforcement, then it’s meaningless--and that’s what they just did,” said Adrienne Hahn, senior counsel for Consumers Union in Washington.

For example, she said, if the plans are the ones to select the people on the independent review panels, instead of state or federal officials, then those reviewers will be beholden to the plans, and might inappropriately take their side in a dispute.

More troubling, she said, is that without federal legislation, consumers will not have an unassailable right to sue their health plans. In Texas, for example, a law was passed allowing consumers to sue, but a recent court decision weakened it. And without that right, consumers will have no power to force a managed-care company to keep its word, Hahn said.

“They have to know that there are consequences for when they deliver a poor product,” Hahn said. “They shirked a lot of big issues and promised a lot of fluff, because there’s no means of holding their feet to the fire.”

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