Gatekeeper-bypass law argued Patients go directly to the specialist

November 21, 1996|By Frank D. Roylance | Frank D. Roylance,SUN STAFF

A little-noticed Maryland law that took effect in October allows thousands of women in managed-care health plans to visit a specialist in obstetrics and gynecology for medically necessary care without first seeing their primary-care physicians.

Some insurers object to the mandate, however, saying it undermines the "gatekeeper" concept that has reduced health care costs and enabled managed-care companies to grow.

Obstetrician / gynecologists contend that the new law spares women unnecessary anxiety and delay and provides more effective treatment for women's most intimate medical problems. And they are urging women to ask their insurers whether the new benefit has been added to their coverage.

Dr. Steven M. Berlin of Cockeysville said one of his patients went to her primary-care physician complaining of an expanding abdomen and swollen legs. Because her symptoms did not seem to indicate a specific gynecological problem, she could not get a referral to a specialist.

The primary-care doctor performed a pelvic exam and found nothing wrong, Berlin said. Three months later, the woman's symptoms worsened, and she went to Berlin without permission. He performed an ultrasound exam and found an ovarian cyst. He called the primary-care doctor and got the referral after the fact.

Removed in surgery, the benign growth weighed 17 pounds. The woman has since fully recovered, he said.

Berlin is legislative committee chairman and a former president of the Maryland OB/GYN Society, which is represented by lobbyist Ira C. Cooke.

Cooke, who helped win passage of the legislation in the 1996 General Assembly, said many women who have gynecological problems want to go directly to a specialist because of the "unique" nature of the relationship. "They don't want their most intimate physical details in the hands of a stranger," he said.

For physicians, having to clear OB/GYN treatments with a primary-care physician adds "significant delays" and can lead to "life-threatening late diagnoses of cancer," Cooke said.

But HMOs oppose any state-mandated benefits, and they fought the bill seeking direct access to specialists, whose fees are higher than those of general practitioners.

"To be able to self-refer to any specialist causes tremendous problems with how managed care works," said Martha C. Roach, executive director of the Maryland Association of Health Maintenance Organizations. "It dilutes the primary-care physician having control over your health care."

It also invites similar demands from other specialists.

"Can't you hear every one of the specialty groups saying the same thing?" Roach said. "They are all clamoring for it."

Cooke said "the vast majority" of insurers have been "going along with the spirit of the law."

But Berlin and Dr. Charles Greenhouse of Silver Spring, president of the Maryland OB/GYN Independent Physician Organization, complained that the state's largest managed-care company -- Mid Atlantic Medical Services Inc. (MAMSI) -- is not giving many of the women it insures direct access to OB/GYN physicians. They said MAMSI is waiting until the employers' insurance contracts are renewed.

The benefit is also being withheld from women holding policies through companies that have 50 employees or fewer.

Paul E. Dillon, MAMSI's senior vice president and treasurer, said last week that the company is simply "following the law. This has been talked about and made very clear to the physicians."

State officials backed up Dillon's position on when the direct-access benefit must be added to policies.

Assistant Attorney General Dennis W. Carroll Jr., counsel to the state Insurance Administration, said that, without specific language to the contrary, mandated benefits are "presumed" to apply to health insurance contracts as they are written or renewed in the months after the effective date of the law. "Otherwise, you're in the position of requiring that contracts be rewritten after the fact. That's not customary," he said.

Likewise, state officials say MAMSI is within its rights in not offering the direct-access benefit to employees of businesses with fewer than 50 employees. That's because the state agency that controls the benefits package for such employees elected not to add it.

John M. Colmers, executive director of the Health Care Access and Cost Commission, said the commission decided on Nov. 7 to exclude the direct-access benefit from the "standard benefit plan" for small companies because of its cost implications -- about $3 more on the average annual premium.

State Del. Marilyn Goldwater, a Montgomery Democrat, last week asked Attorney General J. Joseph Curran Jr. for an opinion on the two issues, saying, "This result was not the intent of the legislation that the General Assembly passed." The attorney general's office is expected to issue a "letter of advice" sometime after Dec. 8.

Pub Date: 11/21/96

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