Panel urges more HMO safeguards

November 10, 1994|By John Fairhall | John Fairhall,Sun Staff Writer

The rapid growth of health maintenance organizations has provoked a conflict over whether the state should barge into the marketplace with regulations to protect the freedom of HMO patients to choose their physicians.

HMOs typically form limited networks of doctors and require patients to choose among them, a money-saving practice that can hold down insurance premiums. But many consumers resent the restrictions, and doctors complain that HMOs can arbitrarily shut them out of their networks.

Searching for a compromise, members of a state task force recommended yesterday that patients and doctors be given some protection in dealing with HMOs and other restrictive health networks.

Although the recommendations stop short of requiring HMOs to contract with every doctor who applies, employers would be required to offer workers a health plan that guarantees freedom to choose doctors.

But the recommendations by a subcommittee of the Governor's Task Force on Community Health Networks have a long way to go before they'd become law.

The full task force must vote on them later this month. If approved, the recommendations would go to the new governor, who had no hand in creating the task force and is under no obligation to act. The recommendations would face a final hurdle -- and an almost certain fight -- in the General Assembly.

The subcommittee's work faces opposition from HMOs, which say they already offer safeguards to protect consumers and doctors.

"We don't believe it's necessary that those regulations be adopted because we typically do those kinds of things," said Thomas P. Barbera, a task force member and executive vice president of Mid Atlantic Medical Services Inc., a Rockville-based HMO company.

Some task force members also note that HMOs are increasingly offering "opt-out" features that allow patients to see a nonnetwork doctor for an extra fee.

The recommendations would require HMOs to:

* Include updated lists of network physicians and hospitals in their marketing materials. The lists would spell out any network doctors who have stopped taking new patients. The intent is to discourage HMOs from signing up consumers on the basis of misleading information about the numbers, names and availability of network physicians.

* Establish internal appeals procedures for physicians who are denied entrance into a network or who are kicked out of one.

* Develop and publicize their criteria for physician membership in their networks.

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