As Americans on Medicare and Medicaid switch to managed-care health coverage, the Clinton administration is moving to protect doctors from being penalized, as many are now, for referring patients to specialists.
Officials of the Health and Human Services Department are completing regulations to take effect Jan. 1 that designers say will prevent doctors from having to choose between sending a Medicaid patient to a specialist or possibly losing reimbursement money."We've struck the right balance between too much unnecessary care and the danger of under-service," said Bruce Fried, director of the department's Office of Managed Care. "The consumer wins."
"The intended effect of this is consumer protection, and we're strongly behind that move," said a spokesman for Kaiser Permanente, one of the nation's largest HMOs. "In broad terms, this regulation is on the right track."
The government is the nation's largest purchaser of health-care coverage. Given the explosive rise in the expense of health care over the past two decades, it has long sought ways to cut costs as programs such as Medicare and Medicaid took larger and larger chunks from the federal budget.
So a shift to managed care was obvious, as such plans rigidly cut costs wherever possible and are designed to serve large numbers of people.
Some have complained that the managed-care switch has a down-side, however. More and more consumers worry that by penalizing physicians for making referrals to specialists, cost-conscious HMOs tempt doctors wary of losing income not to refer patients for needed special treatment.
Penalties often come in the form of refusal to reimburse the physicians for the visits that led to the referral, or for diagnostic tests or other expenses associated with it. Some plans withhold reimbursement in amounts equal to the cost of referrals, if a physician's referrals cost more than 25 percent of his annual payment from the HMO.
The new rules take on special importance, given the huge growth in the number of Medicare and Medicaid recipients who now receive medical treatment through managed-care systems.
Almost 12 million Americans on Medicaid are treated through HMOs, 140 percent more than in 1993. The 4.5 million Americans on Medicare treated through managed-care represent 87 percent more than in 1993.