Rigidity breeds regulation, while flexibility leads to creativity.
Examples of this dictum occur far too frequently in the mixed-up world of managed care, where many patients don't pay attention to or don't understand rules and restrictions until it's too late to do much about them.
And these patients must navigate within an environment where health plans are much better at managing costs and demand than they are at managing care. The result is a system built on utilization control, limits on patient access and heavy policing of provider activity. Not surprisingly, rigid rules proliferate.
Thus, HMOs and health plans are hammered for their heartlessness and inflexibility in making coverage decisions about certain treatments and procedures. In response, politicians are quick to legislate plans.
This year will showcase a flurry of populist proposals designed to win votes and protect patients. The National Conference on State Legislatures says 25 states will consider mandating health plan coverage of contraceptives. All told, state lawmakers will look at dozens of mandates, ranging from cancer screenings and hearing tests for newborns to experimental treatments and reconstructive surgery for women who've had mastectomies.
In Maryland, 30 specific health mandates already account for more than 15% of premium expenses on a cost basis. The state's Health Care Access and Cost Commission estimates the cost of covering mandates equals almost 2% of the average wage paid to workers. The commission recommends that mandates face an annual review and that their cost be capped at no more than 2.2% of the average annual wage.
The review is a decent idea, but rather than imposing rules and caps, how about using a dose of creativity? Health plans might escape onerous regulation by offering flexible and better-defined options. Patients' sharing the cost of experimental treatments, incentives to use the least costly version of a drug and higher copayments for treatments that enhance patients' lifestyles are just a few options. It's time for providers and insurers to introduce managed-care innovations that help patients understand the implications of their desires.