I. Comparable Managed Care entities shall be subject to comparable standards.
Comments: Committee members recognized that PPOs are essentially unregulated while HMOs are heavily regulated. Since both entities represent to the consumer a select panel of physicians and hospitals, for example, both should be held to some basic quality standards. The group found this logic unassailable and strongly supported the above recommendation.
While the support was unequivocal at some level, all members were concerned that taking such a step could end up with overburdening small or developing entities with unnecessary regulation. Specifically, while all agreed that a statewide PPO should be able to meet some basic regulations regarding the quality of their network, all of the participants were concerned that the same regulations be careful not to overburden a small group of physicians or a rural PHO whose resources would reflect their small scale operations. Should any attempts to correct the current regulatory inequalities cross this important but difficult to define boundary, the Committee members would be unsupportive.
II. Adopt standard definitions for "Emergency Care" using a "common sense" standard.
Comments: The discussion centered around use of a definition similar to a "prudent layperson" definition. "Prudent layperson" in and of itself is too ambiguous (what is prudent and what is the standard for layperson?). The American Association of Health Plans offered a recently adopted definition which seemed to the group to address the major concerns more clearly. The group believes whatever definition is used should be developed by the Health Department using their normal mechanism for rule changes.
III. Support Health Department regulation which provides that health care providers cannot be prevented either by direct or indirect sanctions from communicating the patient care options available.
Comments: There was strong support across constituencies to outlaw "gag clauses" in managed care contracts in Oklahoma.
IV. Establish simple, standardized, centralized and uniform criteria for provider credentialing.
Comments: The current credentialing process is universally accepted to be both important and extraordinarily cumbersome. The group strongly endorsed an effort to move toward unified primary verification and common forms throughout the industry. This would significantly reduce the amount of paperwork in the provider's office by addressing primary verification once (confirmation of medical licensure, DEA number, etc.). In addition, standardization of the other forms would allow providers to avoid the significant duplication that currently goes on. These steps would still allow for the managed care organization to establish their own standards for who would and would not be added to their network.
Several Task Force members suggested that physicians should be provided reasons for non-acceptance or non-renewal when requested by the physician.
V. Special populations have unique needs requiring prospective demonstration of the requisite capabilities. The governing agency should prospectively develop criteria designed to ensure unique capabilities exist within a managed care entity which seeks permission to expand into services for patients or delivery system areas which are fragile (persistently mentally ill, substance abuse, aged, blind, disabled, rural areas, etc.).
Comments: The discussion on this recommendation revealed how fruitful it would be for the managed care industry and the advocacy groups to significantly increase their dialogue. The advocacy groups are very concerned that cookie cutter approaches to managed care will be applied to vulnerable populations. The ready agreement that vulnerable populations with special needs require special capabilities indicates much more consensus across these groups than one might have anticipated.
The governing agencies need to ensure that the affected populations and their advocates are involved in clarifying the unique needs of these unique populations.
VI. The Task Force endorses efforts to produce meaningful and concise information to enable consumers to make informed choices among managed care entities.
Comments: This consensus recommendation followed significant discussion about report cards and information sharing in general. The group generally agreed that clear accountability of the health care system will not be accomplished until meaningful information is shared with the decision-makers including the consumers. Concerns about how to proceed with this included who should develop the report cards, the validity of the information in the report cards, the ability of report cards to measure items which are important (as compared to just simply easy to measure). The State needs to urge much additional public and private sector work in this area. The governing agencies should ensure marketing materials clearly reflect what is and is not covered.
VII. The Task Force endorses regular quality assessment for managed care organizations which follow the standards for National Committee for Quality Assurance or, at a minimum, the following six criteria: quality improvement, credentialing, members rights and responsibilities, preventive health services, utilization management, and medical records.
Comments: This recommendation was a natural corollary of recommendation Number I. However, it was recognized in the discussion that not all managed care vehicles can meet the rigorous systemic quality standards to which HMOs are held accountable (through NCQA or like accrediting bodies). However, there was strong support for establishing uniform standards, where possible, across managed care entities to make comparisons possible and to ensure the consumer is uniformly protected.
VIII. The Task Force supports an appeal process which meets the following standards:
Health plans should provide timely notice to the patient when the plan makes an adverse coverage recommendation or decision or when the member disagrees with the provider treatment recommendation. The notice should be accompanied by an easily understood description of the patient's appeal rights and the timeframes for an appeal. Plan should offer an expedited appeals process for situations in which the normal timeframe could jeopardize a patient's life or health. Decisions should be rendered as rapidly as warranted by the member's condition and coverage issue.
Comments: The above definition was supplied by the American Association of Health Plans and agreed to by the group unanimously. This particular issue was brought to the attention of the group through the public hearing process. Certain consumers represented that timely responses by the health plan were not made which impacted the appropriate clinical course of events. The managed care industry and all other task force members strongly supported the above standard which would ensure the consumer has timely responses to their needs. The governing agency should define "timely". An appropriate appeals process for providers should also be required
IX. The Legislature should study the ramifications of establishing a consumer advocacy program (Ombudsman).
Comments: Advocacy groups were concerned that some health plan members were not sufficiently aware of their rights and responsibilities. A proposal was made to establish an Ombudsman program for Managed Care consumers within Oklahoma. Other members were very concerned about the duplication such an Ombudsman program would create relative to existing programs that exist at the Department of Health and as required at health plans. In addition, concern was expressed regarding the cost and the bureaucracy of such a program. However, there was uniform concern that all health plan members have sufficient information and support to ensure they are able to exercise their full rights and responsibilities. The group as a whole was very supportive of the Legislature establishing a study to evaluate this issue.
X. The Task Force believes the Legislature should study the feasibility of requiring outcomes studies by Managed Care organizations.
Comments: The group discussed the important next wave in the health care system - outcomes studies. The group discussed the fact that a number of organizations in Oklahoma are engaged in outcomes studies at one level or another. The group believed the Legislature should bring these groups together to assess current efforts and predict future needs. The outcome of such a study would be the coordination of existing efforts and the evaluation of State support of such efforts. This discussion was animated by the recent release of the Department of Health's state of the state report indicating Oklahoma's extraordinarily low health status relative to national norms.