ANNAPOLIS It’s the type of story Delegate Kumar Barve, D-Montgomery, has heard before:
A baby boy from Gaithersburg needs a blood transfusion twice a day to stay alive. The family’s health maintenance organization refuses to pay for the transfusion, and the family calls Barve for help.
“It was really unfortunate. Here was a situation where an HMO would pay for a much more expensive drug even though a blood transfusion was less expensive on a daily basis — because the law didn’t require them to” pay for the transfusion, he said.
The HMO did pay for the transfusions after the family protested. Shortly thereafter, a law was passed covering blood transfusions.
It’s stories such as this one that have brought managed care reform to the forefront of legislative priorities this session.
And support from Gov. Parris N. Glendening, who submitted a patient’s bill of rights last Monday, has put an even greater spotlight on the issue.
On Wednesday, the Senate Finance Committee, which oversees health insurance regulations, will open debate on managed care reform, hearing several bills including the governor’s patient’s bill of rights.
Legislators have said the governor’s bill will be a major focus of managed care reform this session because it expands on legislation passed last year and in previous years. Glendening’s proposed bill would:
— Require insurers to provide out-of-network referrals to a specialist when a primary care
physician is not
available in the
— Allow specialists to serve as the primary care physician;
— Allow standing referrals to a specialist when a
patient has an ongoing need for specialized care;
— Cover prescription medication deemed medically
necessary by a doctor;
— Require a 48-hour stay following a mastectomy or testicular cancer surgery;
— Designate a central consumer information center.
D. Robert Enten, a lobbyist for the Maryland Association of Health Maintenance Organizations Inc., said the organization is carefully scrutinizing managed care legislation for any conflicts that may arise, but added that the industry “supports fast, fair and efficient regulations.”
“So far, the perception of (the HMO association) and its members is that the legislature has dealt with these issues fairly,” Enten said.
Enten and several HMO association members plan to attend the committee meeting Wednesday to hear the discussion.
Other managed care reform bills to be heard this year include: requiring HMOs to give terminated physicians a reason for their dismissal from the plan and altering the review and grievance process for physicians; covering the costs of patients who undergo the first phase of clinical trial treatment for a life-threatening condition other than cancer; extending certain health insurance benefits under special circumstances and within certain time limits; and providing coverage for an annual chlamydia screening test under special circumstances.
Senate President Thomas V. Mike Miller Jr., D-Prince George’s, said many legislators want to see across-the-board consumer satisfaction with HMOs. Therefore, he said most of the bills, including the governor’s, have a good chance of passing this session.
Sen. Thomas L. Bromwell, D-Baltimore County, chairman of the Senate Finance Committee, agrees, but added that a system of checks and balances must also be followed.
“We have to balance economic issues along with the quality of health,” he said. “I think you’re finding that the insurance industry has been beat up pretty badly here in Maryland because, quite frankly, on some issues they really deserve it, but they are sensitized and understand where we’re coming from,” Bromwell added.
Enten points out that quality of care problems “don’t start and end with managed care organizations.”
“Is the industry perfect? No. Does it make mistakes? Yes. We have 4.6 million people in Maryland and three- quarters are under a managed care plan,” Enten said. “It’s very easy to point the finger and say it’s the fault of the insurance companies that these problems exist.”
But Delegate Marilyn Goldwater, D-Montgomery, a member of the House Economic Matters Committee, which also oversees health insurance regulations, said legislators want HMOs to “go back and fulfill what they promised to policyholders, which is managed care not managed cost.”
“Their business is to take care of people, not make money,” she said.
According to Enten, there are economic pressures facing nonprofit and for-profit HMOs. Overall HMO profits are very thin, he added.
“Many HMOs across the country are losing money and it’s a challenge to provide quality health care at an affordable cost because of that,” he said. “If you’re going to stay in business, you still have to be able to meet your expenses.”