Any Willing Provider Laws: A Managed Care Perspective
In April of this year, the United States Supreme Court ruled unanimously that states may choose to force Managed Care Organizations to open up their networks to any provider who is willing to comply with the requirements of a given contract. About half the states in the US have already enacted such laws, although some are quite limited in scope.
In theory, this is a step forward for consumers since it means that MCOs can no longer force them to go only to the low bidder who won the HMO contract. In practice, it may have other ramifications as well. For example, as the National Association for the Advancement of Orthotics and Prosthetics commentary notes, this may paradoxically reduce the likelihood for federal legislation that might make the AWP rules more uniform across the country. [Click here www.oandp.com/resources/ to read NAAOP's report.]
In an interesting article in Managed Care Magazine notes that this ruling may have opened the door to state regulation of HMOs even if they have contracted with self-insured companies. At present, self-insured companies escape many of the checks and balances that apply to insurance policies purchased by individuals. For example, it is often impossible to obtain an external review of a denial of coverage by self-insured companies, which means that their initial denial can simply be rubber-stamped by internal reviewers who are employees or contractors. In my experience, this often results in such arbitrary policies as an exclusion of all electronic prostheses, forcing amputees to restrict their rehabilitation to 30 year-old options.
One other possibility is that this ruling might spur MCOs to develop quality rankings of providers and to create financial incentives for patients to see top tier caregivers. In this scenario, the patient's co-payment costs would be substantially higher should they chose to see a second tier provider. The argument for this approach is predicated on the situation where all providers in a given area have signed contracts with all HMOs, so no further price competition is possible. The skeptical observer might expect MCOs to foster competition to reduce costs in other ways, such as by defining a "quality provider" as one who decreases utilization.
The entire article is posted online at www.managedcaremag.com.
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