Lawmakers face parade of health bills 'Mandates' require reluctant HMOs to cover certain care

At least 25 introduced

Md. Assembly seeks to end growing role as care manager

February 16, 1997|By Michael Dresser | Michael Dresser,SUN STAFF

There are times when the General Assembly's hearing schedule looks more like a medical school curriculum than a legislative agenda.

This year, legislators are considering bills about mastectomies and bills about prostate cancer detection. There are bills about osteoporosis, diabetes and blood transfusions. Bills about testicular cancer, catheter insertion and clinical trials.

All these bills fall into a class called "mandates." They would require health maintenance organizations and other insurers to do things they don't want to be required to do. Some say insurers must cover a minimum length of hospital stay after surgery or childbirth; others would require insurers to cover medical procedures they otherwise might not pay for.

The annual parade of mandate bills has many legislators wondering how 188 politicians in Annapolis ever got into the business of making medical decisions for their constituents. Even the bills' sponsors say they are groping for an elusive "global solution" that would get them out of the business of legislating by body part.

"I don't think you can constantly call on the legislature to micromanage these issues," said Del. Michael E. Busch, the Annapolis Democrat who chairs the House Economic Matters Committee. "It's very hard to sit here and determine -- as emotional as these issues can be -- that we're going to define what the appropriate care should be."

People in the health insurance industry agree. They hate mandates with a passion and point out that Maryland already has about 40 of them -- more than any state.

"It drives up the cost of health insurance -- significantly," said D. Robert Enten, lobbyist for the Maryland Association of Health Maintenance Organizations. He noted that Maryland is the only state to mandate coverage of in vitro fertilization for infertile couples, a high-cost treatment for a condition that is not life-threatening.

Enten said more mandate bills have been introduced this year than ever -- at least 25. "They're hot-button issues. They get a lot of press. The public doesn't get the true picture," he said.

Busch said he has supported some past mandates, such as a minimum 48-hour hospital stay after childbirth, but now he shares some of the industry's concerns. He said he is particularly worried that mandates could drive up costs to the point where employers self-insure -- and thus become exempt from such mandates -- or drop coverage entirely.

"Health care issues are the easiest issues to demagogue," Busch said, adding that HMOs have become "scapegoats."

Busch added, however, that he believes many of the health insurers' wounds are self-inflicted. "They've done some things that just aren't smart for the industry," he said.

An example would be the case of Elliott Robinson, who testified before Busch's committee last week in favor of Baltimore Democratic Del. Carolyn J. Krysiak's bill to require HMOs to cover the patient care costs of people being treated in clinical trials.

In 1993, when he was 45, Robinson was found to have cancer of the esophagus, an all but certain death sentence at the time. His doctor suggested his best chance -- perhaps the only chance -- of survival was a clinical trial at Johns Hopkins Hospital of a new way to treat the disease.

Robinson told legislators his HMO refused to pay for any of the costs associated with the clinical trial, contending that it didn't 00 have to cover "experimental" treatment. He said the HMO would have continued to pay for the standard treatment, which was seldom effective.

"The HMO was reluctant to do anything but feed me antacids for this erosion of my esophagus," Robinson said.

The Rossville man said he finally was able to take part in the trial, but only because his primary care physicians group agreed to jTC absorb about $20,000 of the costs.

At one point, Robinson said, the HMO agreed to cover the cost of cancer surgery, but not if it was performed by the Hopkins surgeon who had done more than 100 of the operations. Instead, he said, the HMO wanted the operation performed by a community hospital doctor who had little experience with the procedure.

"In the end I was taken care of, but I wasn't taken care of by my HMO," said Robinson, who said he is cancer-free today.

Behind each mandate bill lie similar horror stories.

There are the mastectomy patients being pressured to leave hospitals while still groggy from anesthesia. There's the infant denied coverage for life-saving blood transfusions, whose parents were told they should spend their savings and go on Medicaid. There's the $35 prostate cancer test that some HMOs won't pay for despite the fact it can save lives through early detection.

Del. Kumar P. Barve, who has co-sponsored several mandate bills, said people are turning to legislators as a "desperate last resort."

"The amount of hatred that exists between patients and providers on the one hand and insurers on the other is such that communication has almost broken down," the Montgomery County Democrat said.

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