MCOs adjusting to environment
Three recent developments seem to be evidence of some reality-testing on the part of managed care companies.
The gatekeeper era in managed care may be winding down. Many HMOs are trying to simplify and speed things up by easing referral restrictions for specialists. Whether easier access to specialists will be followed by higher costs remains to be seen. Betting on that eventuality, some HMOs are charging up to 15% more in premiums for plans that allow direct access to specialists.
Also, Empire Blue Cross and Blue Shield of New York says it’s gearing up to allow independent third-party reviews of its coverage of experimental treatments for terminally ill patients. The Medical Ombudsman Program and the Emergency Care Research Institute, neither of which has ties to managed care or insurance industries, will act as reviewers. Empire will pay for and be bound by the reviews. A similar law was enacted in California in October of last year.
And finally, managed care plans may begin covering emergency department visits for patients with "reasonable" concern. Coverage would be based on symptoms, not diagnosis. For example, a person with chest pains would be allowed a reimbursable emergency department visit.
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