CA HMOs could face tough new laws
The California Legislature is about to review and vote on more than 100 measures involving major changes in the way HMOs operate that could become models for national change, a Wall Street Journal article reports.
The measures are a result of widespread public mistrust of HMOs and Gov. Pete Wilson's managed-care task force, which completed its work in December. Wilson also sent a list of "principles for reforming managed health care," to state legislators last month.
System for settling patient/HMO disputes
The most important measure to be voted on involves establishing a system for independent review of patient/HMO disputes, the Journal explains. Also a hot topic in Washington, the proposed law would call for disputes to be settled by a third party when patients are denied medical treatments by their HMOs.
Regulators would organize panels of medical experts to resolve disputes over experimental treatments for people with life-threatening diseases. The panels could start to resolve cases this summer.
Other major proposed reforms for HMOs under the legislation include requiring them to provide members with lists of drugs covered under their plans. A timely response from HMOs would also be required when physicians make requests for nonformulary drugs that are medically necessary. If the HMO denies the request, a letter must be sent to the member with a statement explaining the plan's grievance procedures.
In another proposed measure, a new regulatory agency would be created to oversee the HMOs and the medical groups that contract with them and allow them to make treatment decisions.
The agency would gain power over time and eventually gain oversight responsibility for traditional health insurers as well. Sacramento lawmakers are expected to pass a measure to ensure patients gain full access to information on what is and is not covered by different health plans.
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