Additional aftershocks from last year’s passage of managed-care reform in Illinois will begin to reverberate Saturday through health maintenance organizations in Illinois while shaking out some hassles for doctors and patients.
Illinois’ so-called Patients Bill of Rights has already given 2.4 million people enrolled in state-regulated HMOs greater access to specialist physicians and additional procedures to appeal insurance decisions. Those provisions took effect Jan. 1.
Additional measures, set for implementation July 1, will require HMOs to help smooth the transition for patients when they change doctors. Under the new law, HMO patients who change health plans or lose their doctor from a terminated managed-care contract will have 90 days to find a new physician.
Furthermore, HMOs must abide by certain national accreditation standards that doctors say should lead to more timely decisions when managed-care companies decide whether to approve payment on doctor-recommended treatments. HMOs will have to follow requirements of the American Accreditation Healthcare Commission, which regulates “utilization review,” or the process insurers use to decide whether they will approve payment for treatment.
“[The state medical society] worked diligently for four years to get these provisions passed and become law,” said Dr. LeRoy Sprang, an Evanston obstetrician and president of the Illinois State Medical Society. “We’re trying to make sure that more appropriate care is provided to the patient and that it be done in a more expeditious fashion.”
For example, timely decisions must be made within one business day for an urgent medical need or two business days for most other treatments. “It has to be done in a more expeditious fashion,” Sprang said.
Still, the regulations do not cover people who are in preferred-provider organizations, traditional fee-for-service indemnity plans or various self-insured managed-care plans. Most state residents with insurance are in those plans.
“The new provisions are not going to violently change the way we do business,” said Robert Burger, executive director of the Illinois Association of HMOs. “At the HMO level, the new accreditation [standards] don’t have a great impact.”
The new standards, however, may cost providers of medical care some money because doctors and hospitals also will have to abide by the accreditation commission’s regulations.
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“We’re greatly concerned about doctor groups that we contract with because doctors, too, are going to have to meet these provisions,” Burger said. “For smaller doctor groups, depending on their size, they may have a difficult time and an expensive time meeting these provisions.”
But Sprang said doctors will be willing to trade off the expense to improve quality. “Quality-of-care [standards] might require some outlay of resources, but the American public wants quality of care and people understand that,” Sprang said.
Help for hospital: Amid a period of dwindling sources of revenue, Loretto Hospital has established a foundation to support its operations and capital expenditures.
Loretto is on Chicago’s West Side, where it serves the Austin neighborhood.
South Shore Bank of Chicago and Renaissance Hospital Management Inc. of Oak Park have already made undisclosed initial contributions to the foundation. Executives say they hope to eventually raise $10 million in the next several years.
“With the decline in hospital reimbursement and the continuing increase in medical costs, the foundation will play a key role in allowing the hospital to continue providing health care to the medically underserved community of Austin,” said Dr. Vikram Gandhi, hospital medical staff president and foundation board member.
More green for Blues chief? Now that Scott Serota has been named chief executive of the Chicago-based Blue Cross and Blue Shield Association, the trade group’s former executive vice president might be in for a healthy pay raise.
The association wouldn’t disclose Serota’s new annual salary as president and CEO, but his predecessor, Patrick G. Hays, earned $847,000 in 1998, according to the most recently filed tax return of the non-profit trade group. Hays resigned in January from the group, which counts the nation’s 47 independent Blues health insurers as members.
Serota made $458,000 in 1998 as the association’s executive vice president and chief operating officer.
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E-mail Bruce Japsen at [email protected]