Armed with state funds and a new state law, New Jersey patients and providers will join those in other states who have taxpayer-funded programs to help them navigate their managed care plans.
New Jersey's law, which took effect in January, provides $500,000 to two private, not-for-profit agencies to help consumers and providers who believe they've been wrongly denied coverage or who have other complaints about their managed care plans. The funding will increase to $800,000 next year.
Connecticut, often considered one of the bastions of managed care, appointed a managed care ombudsman in August to help consumers select managed care plans and file appeals and complaints.
Most of the attention paid to managed care state agencies has been focused on California's Department of Managed Health Care. It remains the only state-created, state-funded, state-housed agency assigned to oversee the day-to-day operations of health plans and their impact on consumers. That agency, still in its infancy, has come under fire from some physicians.
"The DMHC has been less than easy for us to work with," says Mark Davis, M.D., a urologist in solo practice in Crescent City, Calif. "They're beginning to get the picture that we really need some help with them . . . at least enforcing the laws that are on the books. We need the DMHC to have teeth and enforce the laws (once they're passed). We need them to say, 'We're going to close you down if you don't give us the information."'
DMHC officials see things differently. "I think Californians had lost faith in the managed healthcare system," says Daniel Zingale, first chief of the managed care department. "I think our primary mission is to try to help restore some of that faith in managed healthcare. The best way to do that is to provide a voice to consumers."
New Jersey's program is unlike those of other states, says Harold Garwin, head of the South Orange-based Community Health Law Project, a not-for-profit group that provides legal services and advocates for the disabled.
The program will operate outside the state government but will be funded with taxpayer dollars.
The HMO Consumer Help Law created an ombudsman program to educate the public and help people who feel they've been denied care. That program will be run through two agencies--the Community Health Law Project and Trenton-based New Jersey Protection and Advocacy--that will provide legal counsel and represent consumers in disputes with their health plans. The agencies will be able to get medical records about a case, fill out forms and represent the patient.
Last year, the CHLP ran a pilot program similar to what would occur under the new state law, which hadn't been signed yet. The agency handled 12 appeals, provided counsel to more than 200 patients, mailed between 300 and 400 handbooks and conducted about 40 training programs, Garwin says.
"We are now attempting to work through the bureaucracy to set up the account so they can put out whatever rules they want," Garwin says. "I'm hoping to have the official state-funded program in place in April."
Officials with the New Jersey Association of Health Plans say they have no problem with the new law nor with the ombudsman role that could put its member plans on the defensive.
"I have the philosophical standpoint that any education is a good thing," says Michele Guhl, president of the association. She says there are already a number of processes, including appeals procedures, that are in place through the state's patient bill of rights. "This is not an us-vs.-them situation."
But us vs. them appears to be the landscape--as usual--in California.
The California Legislature created the Department of Managed Health Care in 1999. It was charged with ensuring that health plans covered under the Knox-Keene Act would provide the care they were legally and contractually obligated to give and that patients would have continuity of care.
But health plans and physicians are snarling over what the DMHC is supposed to do and whether it has done that.
"There's a lot involved with the DMHC in what it's either doing or not doing to help us in our fight against insurance companies," says Davis, the California urologist. "We would like them just to enforce the laws that are on the books. We need help in getting insurance companies to give us the information they have."
Physicians have asked the DMHC to force health plans to provide information on capitation and how they make those decisions to physicians, Davis says.
"(Physicians are) essentially cottage industries," Davis says. "We need governmental agencies to help us step in with the laws on the books. They need to take a good, open look at our real dilemma."
Doctors are unhappy because the DMHC has not forced the health plans to pay physicians higher rates, says Bobby Pena, spokesperson for the California Association of Health Plans. "It isn't the DMHC's responsibility to (help physicians) get paid more. Period."
But that isn't the point, says Jack Lewin, M.D., CEO of the California Medical Association.
"When the lobbyist for the health plans says it's all about money, it's clear that that person has never been very close to physicians. It's about caring.
"You do need enough money to keep a practice afloat and to feel like you're providing care for patients that's appropriate," Lewin says. "It's like they don't get it."
The department's role is to protect consumers, Pena says. But CAHP officials aren't 100% happy with everything the DMHC has done.
"We're discussing things like grievances and appeals processes," Pena says. "We have some concerns about . . . how they're defining grievances and complaints. We're at opposite ends of that. We think . . . grievances are significant, are different than everyday complaints."
The DMHC's mission isn't to make the plans or the providers happy, Zingale says. Its goal is to advocate for and protect consumers, he says.
Some of those protections also will benefit physicians and plans, he says.
For example, the DMHC also will enforce the prompt payment requirements, he says.
"I don't think it's in the interest of consumers for the department to micromanage the private healthcare system," Zingale says.
"Our job . . . is to (act) more like a control tower to guide the industry to a more consumer-friendly place. It's important that we are just as vigilant in overseeing the provider groups as we are the HMOs when it comes to financial accountability.
"Physician organizations have not been held to the same basic financial standards of people who sell frozen yogurt."