Massachusetts Attorney General Scott Harshbarger wants new regulations imposed on HMOs in the state and a new office to oversee the plans, although he says HMOs generally have done a good job caring for enrollees.
"Massachusetts has some of the best HMOs in the country, but that doesn't mean there isn't room for improvement or cause for concern," Harshbarger said.
A report on HMOs, released on Feb. 10, was drawn up after the attorney general's office received more than 300 formal complaints, most of them involving denial of care by insurers, during the past two years.
Emergency care is one area cited. Some HMOs reportedly have been accused of denying care to patients who went to emergency rooms thinking they needed urgent care but turned out to have minor ailments.
The report calls for the state to pass a law prohibiting denial of coverage for emergency room services when patients reasonably believe they face a true emergency.
On the national level, the American Association of Health Plans has called on all managed-care plans to pay for emergency room medical screenings as part of the AAHP's HMO self-policing effort (Feb. 3, p. 16).
The Massachusetts report also calls for preventing HMOs from restricting the types of care doctors can discuss with their patients and for letting the Division of Insurance decide whether to license HMOs based on the adequacy of their physician networks.
Patients had complained to Harshbarger's office that they had trouble appealing insurers' refusals to pay for some therapies, and some patients did not know how to appeal, the report says.
The report calls for a law that would require HMOs to develop formal grievance procedures to hear consumer complaints.
The report said one reason HMOs in Massachusetts have been subjected to minimal regulations is that, "to their credit, (they) have provided a high level of service to their members and have not engaged in the egregious practices that have prompted action in other states."
Bo Piela, a spokesman for the Massachusetts Association of HMOs, said he did not think a new office to oversee HMOs was needed.
"We think the current structure in Massachusetts works well," and the state has "sufficient public sector oversight," he said.
Bob Restuccia of Health Care for All, a patient advocacy group, said, "It is exciting to see the attorney general supporting the consumer and looking for stronger regulation of HMOs."