| Cellucci
Files HMO Reform Bill
State House News
Service
JANUARY 13, 1999 -- Gov.
Paul Cellucci today filed a bill to reform
the health maintenance organization industry, calling it an important
part of
a health care agenda that will also include a request for expanded
health
insurance programs.
The HMO bill is broadly designed to make sure decisions about health
care
are always made by doctors, not accountants, and to give HMO enrollees
an
avenue to appeal the decisions of their insurers. A similar bill
was filed by
Cellucci last year. Cellucci differentiated between health care access
and
quality, saying his bill will make sure HMOs enable policy holders
to get the best care possible.
Cellucci said his bill, unlike the bills passed by the House and Senate
last
year, will protect every person enrolled in an HMO about 2.7
million people
presently as well as those in self-insured health plans.
Forty percent of
those insured in Massachusetts were not covered under last year's House
and Senate-approved bills, which died in conference committee, Cellucci
said.
One of the bill's key components is a new independent accreditation
board
in the Department of Public Health. The board will oversee all
managed care
organizations, requiring HMOs to meet minimum standards for emergency
services, resolution of disputed payments, utilization review, physician
compensation and internal grievance procedures.
"Basically, if you don't get accredited you don't do business in Massachusetts,"
Cellucci said.
Other main features of the bill include:
* A prohibition on physicians working for HMOs that lack accreditation.
* A process whereby those denied coverage could appeal to a panel of
clinical experts if they have exhausted the appeals process offered by
their health plan.
* A requirement that managed care organizations cover emergency services
in cases where a "prudent lay-person" believes an emergency existed.
* A prohibition on payment arrangements that place physicians at risk
financially for treatment costs. This measure would prevent doctors
from placing their financial well being ahead of the needs of patients.
Reminded that HMO reform is being widely advocated by Democrats in
Congress, Cellucci said he is concerned with building consensus and
coalitions and getting results. "I'm not here to try to be partisan," Cellucci
said. He added that those denied care by HMOs are only concerned
that a bill is passed to give consumers new protections.
Cellucci said the HMO bill died in July 1998 because the Legislature
was
tied up with its budget negotiations. House Minority Leader Rep.
Francis Marini (R-Hanson) and Sen. Jo Ann Sprague (R-Walpole) said they
will work to make sure Cellucci's HMO bill gets attention in the Legislature.
"I'm sure that we will get an HMO bill out this year," said Marini.
The
goal of the bill is simple to make sure doctors, not accountants,
make
medical decisions. "Nothing against accountants," Marini said.
"Some of my best friends are accountants."
Added Sprague: "It is about time we got this bill rolling. Patient
protections
have been kicking around in the Legislature for the last 12 months."
A House-Senate conference committee controlled by Democrats could not
reach agreement on an HMO reform bill between August and December of
1998. Both branches rushed reform bills through the process in July.
Conferees said they could not settle their differences, but did make progress.
An alternative to Cellucci's bill will likely emerge early in this legislative
session.
Peter Ajemian, a spokesman for the Massachusetts Association of HMOs,
said the organization is reviewing the bill and others like it filed
this year.
The bill's application to self-insured plans as well as HMOs is fair,
Ajemian
said. In general, Ajemian said, "Our association will support only
legislation
that we think truly benefits consumers without adding unnecessary costs
to the system . . . There's not a lot we would have to say at this point."
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