HMO group offers to accept U.S. regulation But coalition opposes expanding right to sue


WASHINGTON -- A coalition of 25 health maintenance organizations said yesterday that it was willing to accept substantial federal regulation -- much more than the Republican leaders of Congress want.

In a move that they said should restore public confidence in their industry as it is buffeted by sharp partisan attacks, the HMOs endorsed a series of guarantees, including coverage of emergency room care, grievance and appeal procedures for patients, and assured access to specialists.

But the group said it opposed one major provision demanded by Democratic congressional leaders: a wide expansion of patients' ability to sue HMOs and insurance companies when medical benefits are improperly denied.

The coalition, known as the HMO Group, said that patients could resolve such disputes by appealing to an independent panel of medical experts.

The HMOs, mostly nonprofit organizations, supported legislation being developed by Republican Sen. John H. Chafee of Rhode Island and Democratic Sen. Bob Graham of Florida.

The Chafee-Graham plan is intended as a compromise between a Democratic leadership proposal, which includes the right to sue, and legislation being drafted by Republican leaders of the Senate and the House.

The HMO Group, which represents 25 HMOs with more than 6 million members in 26 states, has endorsed these proposals:

HMOs would have to disclose more information on costs, benefits and the quality of care.

HMOs would have to pay for emergency care in any situation that "a prudent lay person" would regard as an emergency.

HMOs would have to allow access to appropriate specialists.

People denied care or coverage could demand a review first within their HMO and then before an independent panel of medical experts outside the health plan.

HMOs could not use financial incentives as an inducement for doctors to reduce or limit medically necessary services.

HMOs must insure "continuity of care" for patients receiving a course of treatment from a particular doctor.

HMOs covering a limited number of prescription drugs would have to make exceptions for patients who could show that they need other medications.

Pub Date: 7/14/98

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