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Managed Care – Myth and
Reality
Issue: Managed care reform has been the leading health care
issue since the defeat of the Clinton health care bill in 1994. The
medical community, proponents of managed care reform in Congress and
the popular media have sought to "demonize" managed care as cost-
instead of consumer-conscious.
NAM Position: The National Association of Manufacturers
supports the many different varieties of "managed care" as important
options for the health coverage purchaser – whether business or
individual – to select from. The NAM strongly opposes efforts to
expand federal regulation of the health care marketplace –
particularly efforts to expand health care liability to employers
and health plans, and proposals to sacrifice workers’ coverage for
provider protections.
MYTH: Physicians are routinely
second-guessed and overruled by health plan
bureaucrats.
REALITY: Physicians report that health
plans approve coverage for virtually all (97% or more) of the care
they recommend (U.S. Department of Labor, 1998).
MYTH: Clerks and accountants deny care.
REALITY: Nurses and other non-physician health professionals
most often approve care. Health plans almost universally use physicians to review potential denials of coverage.
MYTH: The growth of managed care has
restricted patient choice.
REALITY: The growth of managed care has expanded the options
available to consumers. Nearly all (92%) employees are given a
choice of joining a plan that covers out-of-network physicians and
hospitals.
MYTH: Health insurance plans are largely unregulated. ERISA
preempts most state regulation of employer-sponsored
insurance.
REALITY: Health plans are regulated at both the federal and
state level. This regulatory framework is supplemented by private
accreditation standards as well as private purchaser requirements.
Additionally, state laws regulating utilization review are not
preempted by ERISA.
MYTH: People are unhappy with managed care.
REALITY: Surveys consistently show 90 percent approval for
their health plans. In fact, satisfaction with HMOs is equal to or
higher than that of fee-for-service plans. Health plan members in
poor-to-fair health report satisfaction ratings for HMOs and PPOs
that are comparable to satisfaction for their counterparts enrolled
in fee-for-service plans, and several studies show higher
satisfaction rates for health plan members. |
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