GOVERNMENT & MEDICINE

States beat Congress in passing health laws

Physician groups in some states back independent appeals of health plan decisions over HMO liability.

By Geri Aston, AMNews staff. July 31, 2000. Additional information

Washington -- State legislatures this year forged ahead on health initiatives important to physicians that have confounded Congress for years.

"Nobody in their right mind would wait for Congress to act," said Gordon Smith, executive vice president of the Maine Medical Assn. "[Bills] get caught up in election-year politics and partisanship in Congress."

Top among the issues tackled by states are external review of health plan care denials; health plan liability; parity in insurance coverage for mental illnesses; prescription coverage, especially for low-income seniors; and insurance coverage for routine care for people in clinical trials, according to a Blue Cross Blue Shield Assn. analysis of state action.

Some states, and their medical societies, supported establishing patients' rights to appeal health plan care denials to an independent body over creating a right to sue insurers.

"It's more important to us that the patients get the care when they need it," said Janet Monahan, a spokeswoman and lobbyist for the New Hampshire Medical Society.

The group pushed for an external appeals process in conjunction with a requirement that health plan medical directors be licensed as physicians and subject to the same standards by the state's medical board, she said. "With the big stick of the medical board, we hope that medical directors will make good decisions early on."

The Massachusetts Medical Society took a similar stance and supported a patients' bill of rights that includes a host of health plan appeals rules, including independent reviews of care denials.

That measure is expected to gain Gov. Paul Cellucci's signature, which would make it the 10th state external review law passed this year, according to Blues figures.

Initially, the Massachusetts physician group supported calls for health plan liability but changed its position after working in a coalition with the health plans and hospitals, said Francis X. Rockett, MD, the society's president-elect. "What we've come to appreciate is lawsuits don't necessarily result in better health care."

Thirty-two states have considered health plan liability measures, but only four had passed them into law at the time of the Blues study's release.

One such state was Maine, where the liability provisions in the patient protection bill gained the support of the state medical association.

The law is the "best of all worlds," Smith said, because it not only holds health plans liable but also includes tort reform in the form of a cap on compensatory damages.

On a separate front, the rapid rise in prescription drug costs spurred seven states to create or expand programs aimed at helping citizens, usually seniors on Medicare, pay for prescription drugs, said the Blues study.

Typical among the measures is the Florida Pharmaceutical Expense Assistance Program, which gives seniors with incomes between 90% and 120% of the federal poverty level subsidies to help pay for prescription drugs, said Susan Laudicina, Blues' director of state services research.

The issue likely will remain popular among states, especially if Congress fails to pass a Medicare drug benefit before adjourning this fall.

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States passed myriad health care laws this year. Among the hottest topics were:

Health plan liability

• Considered in 32 states
• Passed in four: Arizona, Maine, Oklahoma, Washington

Mental health parity

• Considered in 20 states
• Passed in five: Kentucky, Massachusetts, New Mexico, South Carolina, Utah

External review

• Considered in 17 states
• Passed in nine: Alaska, Kentucky, Maine, Michigan, New Hampshire, South Carolina, Utah, Washington, Wisconsin

Pharmacy coverage

• Considered in 17 states
• Passed in seven: Florida, Illinois, Kansas, Maine, Maryland, New Hampshire, South Carolina

Clinical trial coverage

• Considered in 17 states
• Passed in three: Arizona, Maine, New Hampshire

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Additional information

Box: State activity