Making the Best of Managed Care.

• Author: Cauchi, Richard

State ombudsman, report card and profile programs aim to aid those frustrated by HMOs.

It was the worst medical news. A young Vermont woman, "Ellen," had breast cancer, and her managed care company refused to cover treatment by a recommended specialist because he was outside its network.

Another HMO horror story? Not quite. Within three months, Ellen took her case to a new state office that was able to negotiate full treatment for her. The Montpelier office of the health care ombudsman talked repeatedly with her insurer and provided the medical information they needed. The ombudsman also worked with her oncologist; as a result the HMO agreed to cover treatment. Then Ellen received a notice that she was going to be dropped from the plan. The ombudsman office again negotiated with her HMO. This time they agreed to continue her health coverage, but under a different group policy.

Not all cases have such clear results, but in a growing number of states, laws to protect managed care patients appear to be working- with less disagreement, less litigation and, some say, healthier enrollees.

The number of Americans enrolled in managed care surpassed 180 million last year. And between 1995 and the end of 2000, more than 45 states passed their own laws regulating that care. These laws still vary from state to state--covering access to care, quality, the right to information and the avenue to complain. The statutes themselves can be complex--often filling 40 pages, and covering many topics.

Within the HMO debate, a recent trend is emerging and is especially reflected in more recent laws. It can be summarized as "making it work." This approach may sound obvious, but it also remains contentious.

The kinds of legislation being designed to make HMOs work better include:

*Consumer report cards--Widely published, easy-to-read reports that compare all the major competing managed care health companies for quality, finances and services.

* Doctor profiles--Easy to get public records with details about doctors so consumers can spot strengths such as training and credentials as well as cautions such as medical board sanctions or malpractice judgments.

* Ombudsman or consumer assistance offices--State-funded but independent offices that act on behalf of a patient who is unable to get needed medical care.

A common thread among these mandatory, state-created policies is that they no longer seek to discredit or block managed care as a predominant way Americans get health care. Instead, each provides a practical tool to assist or reassure patients, while allowing the health insurers (both nonprofit and for-profit companies) to continue in business and even grow or thrive.

THE REPORT CARD...