A coalition of hospital and physician groups is pushing a set of guidelines for managed-care plans and their network providers to follow to ensure access, quality and choice for their enrollees.
The Coalition for Accountable Managed Care, which includes the American Hospital Association, Catholic Health Association, InterHealth and several other provider groups, last week released a document that outlines the policies intended to guard patient and community healthcare standards (See related story, p. 36).
"Principles for Accountable Managed Care" builds on a previous document, endorsed by some of the same groups, that set ground rules for rival providers to follow so healthcare standards aren't sacrificed in the more competitive marketplace of the future.
For example, that document called on providers to make their costs more competitive through efficiency, prevention and higher quality rather than by avoiding high-risk or uninsured patients.
Although the coalition's new managed-care principles are pointed at health plans, they say providers share in the obligations.
That's particularly true where hospitals are transforming themselves into managed-care networks, said Richard Wade, the AHA's senior vice president for communications.
"They're assuming risk, and that's new territory for them," Wade said. "As they begin to develop their own managed-care networks, they have a set of principles that they can follow."
But the groups said the document shouldn't be interpreted as a call for government regulation.
"We're trying to identify the components that make managed care work," said Jack Bresch, lobbyist for the CHA. "It will give you an idea of the kinds of parameters that should be incorporated into managed care. We are not arguing for mandated standards, but we are arguing for standards."
The American Association of Health Plans, which represents managed-care plans, had no immediate comment on the coalition's guidelines.
The coalition said health plans should:
Not discriminate against the poor, disadvantaged or chronically ill in enrollment.
Offer a comprehensive benefit package that includes clear rules for access to specialists and a range of providers.
Meet recognized certification and quality standards and ensure that practitioners are appropriately trained and credentialed.
Give autonomy to practitioners in clinical decisionmaking, and structure financial incentives to ensure appropriate and high-quality care. In particular, it said plans shouldn't limit clinical discussions between practitioners and patients for financial reasons.
Improve community health status by promoting healthy behavior both among enrollees and nonenrollees.
Give consumers detailed, useful and understandable information on their plans.
Peters Willson, vice president for public policy with the National Association of Children's Hospitals, said the principles call for health plans to support critical services-such as treating low-income patients and supporting research and educational activities-that are jeopardized by cost-cutting incentives in managed-care contracts.
"The new capitated marketplace is not structured to address those," Willson said.