"There is little evidence these laws have much impact on providers' economic concerns," said Mark Hall, J.D., professor of law and public health at Wake Forest University Baptist Medical Center.
Hall reviewed managed care patient protection laws in the 48 states that have enacted them and also surveyed state regulators about law content. Commonly known as patients' bills of rights, these laws are aimed at restraining the perceived excesses of managed care, including "gate-keeping," or denying insurance payment for medically necessary treatment and restricting patients' choice of physicians Critics of the laws, however, say they actually provide protection to providers. Hall's research was designed to assess the validity of these claims by evaluating the laws' impacts.
After completing a review of state laws, Hall conducted in-depth case studies of six states – Iowa, Louisiana, Michigan, New Jersey, Texas and Virginia. The states were selected to ensure variety in location and size, the extent of patient protection laws and the market share of health maintenance organizations.
In each state, Hall conducted 16 to 24 confidential interviews with health plan managers, physician practices, regulators, patient advocates, industry observers and others. He also conducted a focus group with nine health care lawyers from across the country and conducted interviews at four of the largest national health plans.
Hall found that most of the patient protection laws are dominated by provisions that are directed primarily at patients' rights. Laws that are directed primarily to providers' interests are less frequent and are not very strong.
"The laws targeted most directly to protecting providers are not especially prominent in the overall package of state patient protection laws," writes Hall in the article.
One goal of the interviews was to determine whether provider interests were the main impetus for enacting the laws. Interviewees gave three primary reasons for the laws: media attention to managed care "horror stories," reaction to routine complaints about managed care, and a desire to prevent problems from arising.
"Provider advocacy and provider interests didn't stand out as the dominant forces leading to enactment in most states, or nationally," said Hall.
When it comes to the effects of the laws, Hall found much the same thing: there is little evidence that they help providers economically. He reviewed the laws' provisions that address whether insurance companies can exclude certain providers from their panels, how providers can be terminated from panels and other aspects of providers' relationships with health plans.
He found that the laws do not deter health plans from being selective about which providers they include, do not create significant barriers to terminating providers and do not greatly improve the economic situation of providers.
"We found that managed care patient protection laws do not advance the agendas of providers more than they protect consumers," said Hall. "Instead, they appear to embody a convenient alignment of interests among providers, patients and lawmakers."
Hall said the findings are consistent with findings from similar studies, including one that found that these laws are a "curious mix of consumers' rights, provider protection and patient protections."
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About Wake Forest University Baptist Medical Center: Wake Forest Baptist is an academic health system comprised of North Carolina Baptist Hospital and Wake Forest University Health Sciences, which operates the university's School of Medicine. The system comprises 1,282 acute care, psychiatric, rehabilitation and long-term care beds and is consistently ranked as one of "America's Best Hospitals" by U.S. News & World Report.
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