Editorial: Oversight of HMOs a necessity

Sunday, Feb. 28, 1999 | 9:30 a.m.

But guess what happened? Even though there was no new HMO legislation, premiums shot up anyway for many Americans enrolled in managed care. And last week the Associated Press noted that most of the biggest HMOs recently reported healthier-than-expected fourth-quarter earnings, with prospects even rosier for 1999. Along with raising premiums, analysts said reductions in payments to doctors and the dropping of unprofitable Medicare patients contributed to higher profits.

While HMOs expressed doom and gloom about any regulation in 1998, their mood certainly has changed. Now HMO lobbyists say they are willing to accept some regulation. For instance, the American Association of Health Plans says it is willing to let a patient challenge an HMO's decision, permitting an appeal to a doctor outside his health plan.

One obvious reason for the HMOs' about-face is that the Republicans' majority in the House has been reduced, making it more likely that moderate Republicans will join Democrats in passing a patient's bill of rights. Another factor may be an acknowledgement that trying to defeat the legislation is more difficult, given their increased earnings.

HMOs do good work in preventive care, as was demonstrated in a study released last week that showed HMOs have done a better job than traditional fee-for-service providers when detecting breast cancer. But problems typically tend to occur after the patient has an injury or an illness that requires extensive treatment, for which HMOs sometimes stubbornly balk at paying.

Obviously the pleas of poverty HMOs made last session can't be used this time, which creates a great opportunity for reform advocates. Congress needs to pass a patient's bill of rights, including the right to sue an HMO when care is denied, that will give HMO customers a needed voice.