Sponsor: Rep. Jim Howell
House Bill 4483
Sponsor: Rep. Judith Scranton
House Bill 4484
Sponsor: Rep. Patricia Birkholz
Committee: Health Policy
First Analysis (4-27-99)
THE APPARENT PROBLEM:
The health needs and concerns of children differ from that of adults. In a policy statement dated November, 1992, the American Academy of Pediatrics stated that "the medical care of infants, children, and adolescents ideally should be accessible, continuous, comprehensive, family centered, coordinated, and compassionate" and should be "delivered or directed by well-trained physicians who are able to manage or facilitate essentially all aspects of pediatric care." Pediatricians receive an additional three to four years training completing a pediatric residency, and so are well equipped to diagnose and treat the illnesses, as well as provide preventative care, for children and young people from birth through the age of 21.
However, with the move away from traditional health plans to managed care plans, not all people have equal access to pediatric care for their children, as some managed care plans require all participants to be treated by a family physician and obtain referrals for all "specialist" care, including the services of a pediatrician. Last year, Public Acts 401, 402, and 412 of 1998 amended the various health insurance laws to require insurers to allow women to see an obstetrician-gynecologist (ob-gyn) for annual well-women examinations and routine obstetrical and gynecologic services for those plans that require a female enrollee or member to designate a primary care provider. Since pediatricians provide a comprehensive medical service to a defined population in a manner similar to ob-gyns, it has been argued that parents should be able to select a pediatrician to be their child's primary care physician, if so desired, rather than having to obtain a referral in order to gain access to a pediatrician's services.
Reportedly, the majority of managed care health plans in the state that require participants to designate a primary physician or "gatekeeper" do allow parents to select either a family physician or a pediatrician as their child's primary physician. Some of the plans require a waiting period of one or more months if the parents should want to change the designation, where other plans allow parents to switch designations only during open enrollment periods. However, though there appears to be few problems at the present time, some people are concerned that in the future, as health care costs continue to climb, managed care plans may come under increasing pressure to institute further cost containment initiatives. In order to address this concern, legislation has been introduced to protect the current level of accessibility that parents have to pediatric services for their children's health care.
THE CONTENT OF THE BILLS:
The bills would, in general, require health insurers to allow a dependent minor enrollee or member to go to a participating or affiliated pediatrician for pediatric care services without having to have prior authorization or referral from a primary care provider for those insurance plans that require enrollees or members to designate participating primary care providers. A health insurer could require prior authorization or referral for access to a nonparticipating pediatrician.
House Bill 4482 would amend the Nonprofit Health Care Corporation Reform Act (MCL 550.1101 et al.) to apply to group and nongroup certificates of Blue Cross and Blue Shield of Michigan. House Bill 4483
would amend the Insurance Code (MCL 500.100 et al.) to apply to expense-incurred hospital, medical, or surgical policies and certificates of commercial health insurance companies. House Bill 4484 would amend the Public Health Code (MCL 333.1101 et al.) to apply to group and individual contracts of health maintenance organizations (HMOs).
FISCAL IMPLICATIONS:
According to the House Fiscal Agency, the bills are not anticipated to have a significant fiscal impact on state or local government. Some increased costs could occur if the services provided by a pediatrician exceeded those that would have otherwise been provided by the primary care provider, but the extent to which that would occur is not quantifiable. (4-21-99)
ARGUMENTS:
For:
Though few if any problems have been reported with parents being able to take their children to pediatricians if covered by a managed care plan, the intent of the bills would appear to be an attempt to protect the current accessibility. Most managed care plans allow their members or enrollees to designate either a pediatrician or a family physician for their children's care. If a family first designates a family physician, and then wishes to change to a pediatrician, some plans may require a waiting period of 30 days or so, or may require a parent to wait until the next open enrollment period. However, as health care costs continue to rise, pressure may mount on managed care plans to implement tighter cost control measures. The bills would add a level of consumer protection against future changes and are fitting in light of recent Patient Bill of Rights legislation enacted in Michigan, the legislation allowing women greater access to obstetrical and gynecologic services, and proposed federal legislation pending before the U.S. Senate that would provide for greater accessibility for specialist services.
For:
Because pediatricians are specially trained in the medical care of children, adolescents, and young adults, as well as with regard to mental health needs and behavioral disorders, allowing parents to designate pediatricians as primary care physicians would most
likely result in long-term cost savings. Pediatricians would be better able to assess a medical condition, treat that condition, and assess when referral for specialist care would be appropriate, thus eliminating or reducing delays in treatment that could drive up the cost of medical care.
Against:
Some have expressed the concern that the bills fly in the face of the notion of managed care by increasing the range of exceptions to the requirement of designating a primary care physician and obtaining referrals for specialist care. Besides, the bills really are not needed. Most managed care plans in Michigan already allow for the designation of pediatricians as the primary care physician. Also, since the majority of Michigan residents with health coverage are covered by self-insured plans that are exempted from state laws under provisions of the federal ERISA legislation, few people would actually be affected if the bills became law.
POSITIONS:
The American Academy of Pediatrics/Michigan Chapter supports the bill. (4-22-99)
Blue Cross/Blue Shield of Michigan supports the bill. (4-26-99)
The Health Insurance Association of America has no position on the bills. (4-27-99)
The Michigan State Medical Society has no position on the bills. (4-27-99)
The Michigan Association of Health Care Plans does not support the bills. (4-27-99)
The Michigan Osteopathic Association opposes the bills. (4-26-99)
Analyst: S. Stutzky