DATE: Monday, July 7, 1997                  TAG: 9707070028

SECTION: FRONT                   PAGE: A4   EDITION: FINAL 

TYPE: Focus 

SOURCE: BY DAVID S. HILZENRATH, THE WASHINGTON POST 

                                            LENGTH:   61 lines

FOCUS: MANAGED-CARE BACKLASH MANAGED CARE HAS HELPED SLOW THE RISING COST OF HEALTH CARE, BUT NOW SOME CRITICS ARE FINDING THE CURE WORSE THAN THE DISEASE. THE RESULT: A PATCHWORK QUILT OF NEW REGULATIONS TO CONTROL THE PENNY-PINCHING.

this date.] ILLUSTRATION: FILE PHOTO/Knight-Ridder Tribune

GRAPHIC

MANAGED CARE WHAT IS IT?

Health insurance that seeks to cut the cost of care by:

Restricting access to medical specialists

Limiting choice of physicians

Reducing the length and frequency of hospital stays

Giving doctors pay incentives to practice efficient medicine

Measuring physicians' use of medical resources

Requiring advance approval of expensive tests and treatments

THE IMPACT:

The cost of health-care benefits, which was climbing by 10.1

percent in 1992, rose by only 2.5 percent last year, slower than the

overall 2.9 percent inflation rate.

THE BACKLASH:

In Missouri, a new law requires managed-care companies to pay for

emergency room visits whenever a ``prudent layperson'' would have

reason to believe that immediate care is needed.

In Connecticut, newly passed legislation would allow patients to

appeal to the state insurance commissioner when health plans decide

not to pay for their medical treatment.

Texas has made it possible for consumers to sue health

maintenance organizations for medical malpractice.

By the end of 1996, 28 states and the federal government had set

minimum coverage standards for the length of a hospital stay when a

woman delivers a baby.

This year nine states have ordered coverage of hospital stays for

mastectomies.

At least 23 states have mandated that HMOs allow women some

measure of guaranteed access to obstetrician/gynecologists instead

of leaving that to the discretion of ``gatekeeper'' physicians.

Last year, New York ordered HMOs to allow specialists to serve as

primary doctors for patients with life-threatening, degenerative or

disabling conditions.

As of mid-June, 16 states had enacted requirements involving

coverage of emergency room services.

The federal budget bills passed by the House and Senate last

month would impose some new requirements in federal health insurance

programs, including a version of the ``prudent layperson'' rule for

emergency services. KEYWORDS: MANAGED CARE HEALTHCARE

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