Update on Chapter 141 and the Office of Patient Protection
By Leo L. Stolbach, M.D.
In November 2000 the voters of Massachusetts had the opportunity to
vote on a ballot initiative, proposed by the Ad Hoc Committee and others,
which would have established Universal Health Care and other health system
reforms in Massachusetts. Unfortunately, the voters turned down the ballot
initiative by 52% vs. 48%. It is relevant to point out that the opponents
of the initiative outspent the proponents 50-to-1, with the HMO's contributing
$4 million to its defeat.
Even though this ballot initiative known as Question 5 was defeated
it had a beneficial effect on the state's health care system. The threat
of the passage of Question 5 resulted in the passage of the Managed Care
Reform Act of 2000, also known as Chapter 141, which established a number
of reforms to the way managed care is delivered in Massachusetts. The
Ad Hoc Committee played a key role to promote reform by serving on the
Committees and Commissions set up by Chapter 141, and our group continues
to monitor the extent to which the mandates established by Chapter 141
are being carried out.
The Ad Hoc Committee has seats on the following committees and commissions:
- Advisory Committee on Universal Health Care Access: John Goodson,
M.D.
- Commission on Provider Compensation: Timothy Guiney, M.D.
- Advisory Committee to the Managed Care Oversight Board:
Leo Stolbach, M.D.
The last of these committees, along with the Managed Care Oversight Board,
had the responsibility for reviewing and recommending changes to the regulations
which were promulgated by the Massachusetts Department of Public Health
(DPH) and the Massachusetts Division of Insurance (DOI) to implement the
requirements of Chapter 141. In addition, the Board has oversight over
the work of the Office of Patient Protection.
One of the major accomplishments of the Managed Care Bill, Chapter 141,
was the establishment in 2000 of the Office of Patient Protection (OPP)
within the DPH and its merger with the Office of the Managed Care Ombudsman
(previously established by Executive Order in 1998). As reported on the
OPP website: "Effective January 1, 2001, Massachusetts consumers
and other individuals who receive health coverage from a Massachusetts
carrier, insurer or HMO are entitled to new protections covering internal
grievances, medical necessity guidelines, continuity of care and independent
external reviews."
To accomplish this mission, "Under Chapter 176-O, the OPP is responsible
for:
- Monitoring and regulating health plan compliance with requirements
for internal grievances and appeals;
- Maintaining contracts with at least three independent external review
agencies and administering the external appeal process;
- Ensuring that health plans comply with regulations concerning continuity
of coverage under specific circumstances;
- Receiving and posting information reported by health plans; and
- Creating and maintaining a website with information for consumers
about managed care."
In its Annual Report for 2003, OPP reported that in 2003 it received
446 requests for external review. This figure represents an increase of
33% over 2002 and 228% over 2001. In the 1st six months of 2004, there
have been 162 requests. Of the 446 requests in 2003, 21% were considered
ineligible because the requests are specifically excluded from coverage
by the carrier or the patient's plan is not included in the external review
process (i.e., self-insured, Medicare, government employees, etc.) or
because the patient's case had not yet gone through the HMO's internal
review process. Another 12% were resolved before review, some through
discussion between the OPP staff (including communication by the Managed
Care Ombudsman's Office) and the managed care plan.
Of the cases sent for external review in 2003, the process overturned
or partially overturned 49% of the health plan decisions in favor of the
patient. So far in 2004, 37% of the health plan decisions have been overturned.
Of the various categories of requests for review, the area of Behavioral
Health (mental health) represented 52% of cases in 2002 and 2003. In 2004
this has dropped to 37%. This reduction may be due in part to a specific
intervention by OPP with Blue Cross/Blue Shield (BC/BS) of Massachusetts.
OPP had noted that 60% to 75% of the denials by Blue Cross/Blue Shield's
Magellan Behavioral Health were overturned. This high overturn rate suggested
that there may be problems in the clinical criteria used by Magellan or
in the application of criteria by Magellan's physicians. Following meetings
with BC/BS and Magellan there have been revisions of clinical and administrative
processes and the number of external review requests has significantly
decreased in 2004. Monitoring continues by OPP. This is an excellent example
of the significant role which OPP can play in protecting patients participating
in managed care plans.
In addition to Behavioral Health, the other top seven areas of requests
for review are reconstructive surgery (7%), infertility care (7%), experimental
therapy (5%), inpatient care (5%), rehab services (5%) and durable medical
equipment (5%).
The Office of the Managed Care Ombudsman, under the able leadership
of Stephanie Carter, Esq., also can play a major role in intervening with
the Managed Care Plans to resolve medical care or coverage issues for
patients. As described in the 2003 annual report of OPP. The Office "fielded
more than 2000 calls in 2003. These calls , primarily from consumers,
involved questions about health plan denials, appeals, benefits,and policies.
The Ombudsman's office assists consumers in resolving disputes with health
plans. In addition, if another entity has jurisdiction over the issue,
the Ombudsman's office refers callers to the appropriate state or federal
agency. The Ombudsman's office also answers general questions from consumers
and providers about managed care and Chapter 176-O and refers callers
with general health insurance questions to the DOI or other appropriate
agency."
Many patients and physicians may not be aware of the services available
from the OPP and the Ombudsman's Office. State efforts are underway to
increase the visibility of both Offices. The Director of the OPP is Karen
Granoff and the Director of the Ombudsman's Office is Stephanie Carter,
Esq. Both offices can be reached at 1-800-436-7757. Information regarding
the services available and helpful links can be found at the OPP website
www.mass.gov/dph/opp
Leo Stolbach, MD is a retired Clinical Oncologist.
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