Mark 1996 as the year of the managed-care consumer.
Mandated 48-hour maternity stays, bans on gag clauses imposed on physicians by HMOs, and other "patient protection" measures sailed through state legislatures this year, each passing in at least 16 states.
Portions of the Patient Protection Act, drafted by the American Medical Association, passed in at least 20 states. It was considered in another 15. Eleven states enacted multiple patient protection measures.
The most successful of the act's provisions requires plans to provide patients with information about terms and conditions. It passed in 20 states.
"Fairness" elements such as requiring plans to credential providers based on quality passed in six states. Five states enacted standards for utilization review and four required plans to allow patients to use non-network providers.
The flurry of incremental reforms caught the managed-care industry off guard, said Joy Johnson Wilson, director of the health committee at the Denver-based National Conference of State Legislatures. She predicted managed-care organizations will change their practices to head off further legislation in 1997.
"I think that reflects the growth in the (HMO) industry and the fact that they were inadequately regulated to this point," Wilson said.
Lawmakers retreated from "any-willing-provider" legislation, which peaked in 1994 and 1995. Such laws require managed-care plans to accept all physicians or other providers if they meet the plans' contract requirements. Any-willing-provider legislation passed in just two states, Kentucky and Utah, of the 17 in which it was considered.
The popularity of minimum-stay legislation for new mothers prompts expectations that states will try to pass similar length-of-stay minimums for other procedures such as heart bypass surgeries and vasectomies, said Daniel Stech, a state government field representative at the Medical Group Management Association.
Wilson said it's more likely there will be legislation mandating adequate follow-up after outpatient surgery. She said some states will strengthen their maternity length-of-stay laws to match those passed by the federal government, which pertain only to employer-sponsored ERISA plans. Wilson also expects more legislation on gag clauses in 1997, at both the federal and state levels.
One question is whether the passage of the Kassebaum-Kennedy legislation this year, which marks the first time the federal government stepped in to regulate health plans, will bring about more regulation at the federal level. If so, that could pre-empt state efforts to regulate managed care.
Families USA, a health consumer watchdog group, released a report earlier this year documenting the "avalanche" of managed-care legislation at the state level. The group said HMO consumer protection legislation is uneven, resulting in a "crazy quilt pattern" that will ultimately need to be standardized.
Just entering the picture is legislation to tighten state oversight of conversions by not-for-profit health plans and hospitals into for-profit organizations. California and Nebraska passed laws this year, and other states, including Ohio, are expected to take up the issue in 1997.