On January 14, 1997, this bi-partisan managed care consumer protection bill was introduced into both the New Jersey and Texas legislatures. Shortly thereafter, versions of the same bill were introduced into the legislatures of Colorado, Georgia, Delaware, Kansas, Ohio, Oregon and Tennessee.
The bill stipulates:
- choice of provider, even if outside plan;
- prohibits "gag rules" that forbid providers discussing all treatment options with patients;
- designates agency to monitor managed care plans for quality;
- requires plans to define and disclose policy limitations;
- assures patient access to all FDA-approved drugs and devices;
- offers grievance procedures, reviews, and appeals.
"The bottom line is that we want to do what's right for consumers," said Tennessee state representative Kathryn Bowers(D). "We're hoping this bill will give other state legislatures a template for drafting their own consumer protection legislation."
"This bill can be as valuable to the business of managed care as it is to consumers. Ensuring enrollee satisfaction and quality of care is simply good business," commented New Jersey state assembly member Barbara Wright(R).
DCs looking for specific language that protects patients' right to choose chiropractic won't find it in this bill. Unless a provision can be included that insures a choice of specialists when a referral is made, chiropractors may not be overly enthusiastic about this bill.
Point-Of-Service Option Required
But the silver lining on this model legislation for chiropractors is the requirement in Section 6e:
(e) Each managed care plan shall offer a point-of-service option.Reference(1) The point-of-service option may require that the enrollee in the plan pay a reasonable portion of the costs of such out-of-plan care.This option allows patients to visit their chiropractor with the requirement that the patients cover some of the cost out-of-pocket. Point-of-service plans are relatively new on the managed care scene. They have been available to the general public for less than 10 years. But their growth rate is approximately the same as that of Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).1
While each state legislature will customize the bill to meet the needs of their constituents, chiropractic state associations have an opportunity to inject "chiropractic-specific" language. Depending on the particular plan, the point-of-service option may provide an opening for a certain degree of patient choice within managed care.
As DCs treat their patients over the next year, it would be a good idea for the chiropractors to begin talking to their patients about the point-of-service option. More than 16% of all employees already have this benefit.1 If enough employees ask for it, the employer will work harder to provide it.
Chiropractors and their patients still need to work diligently to secure full, unobstructed chiropractic benefits under managed care. But the point-of-service option, depending on how it is written, could provide your patients with better access to chiropractic care in the interim.
1. KMPG Survey of Employer Sponsored Health Benefits, 1996; 1995; 1994; 1993; 1992.