Public opinion to the contrary, state and local officials are limited in their ability to effectively protect HMO enrollees. Furthermore, they don't belong in the business of making medical decisions. But that won't stop politicians from trying to look like they do.
A virtual feeding frenzy has begun in the wake of anecdotal horror stories regarding HMOs. So any public official with a vested interest in getting re-elected (i.e., all of them) is ready to hop on the bandwagon and denounce gag clauses, drive-through deliveries and limitations on patient choice under managed care.
In New York, Gov. George Pataki has jumped into the fray with a wide-ranging legislative package billed as an effort to strengthen protection for HMO enrollees. Four states already have passed similar legislation. Give the governor credit for winning support for his proposal from insurers, physicians, consumers and business leaders.
The proposal would help make the public more aware of the workings of their health plans by requiring that plans provide information to their enrollees about such things as what drugs they will pay for, the guidelines they use to reject claims, and the design of the consumer grievance procedures. It also contains protections for physicians and other providers whose contracts have been terminated by HMOs.
However, when the legislation strays beyond informational requirements, it gets into murky waters. For example, it would require reimbursement for people who mistakenly go to emergency rooms thinking they are covered, even if their problems are not life-threatening. This is hardly a prescription for increasing public responsibility for making decisions about cost-effective, quality treatment options.
Moreover, requirements for establishing internal arbitration procedures could backfire if the public views HMOs as both judge and jury, insulated from outside influence.
Improving the quality of health plans is a vast challenge. At the most basic level, HMOs overlay an unnecessary layer of bureaucracy on the healthcare delivery system. In addition, bloated overhead costs for marketing, executive salaries and claims processing funnel dollars away from patient care.
State legislation may be unavoidable under the circumstances. Let's hope New York legislators can resist the temptation to load up the bill with requirements that managed-care plans be forced to hire doctors who may not share their philosophy or to make plans send enrollees outside the network-without sharing in the cost.
The best way to assure quality is for educated patients to choose with their feet, using patient-satisfaction surveys that allow them to determine which plans are best able to meet their needs for quality, convenience and access.