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Doctor Gag Rules Defended

October 30, 1996
By: Andy Kravetz
State Capital Bureau

JEFFERSON CITY - Representatives of Missouri's managed health care industry urged lawmakers to drop the idea of giving doctors legal rights for full discussions with their patients.

Several health industry representatives told the Joint Interim Committee on Managed Care Wednesday that they did not think problems such as "gag rules" on doctors were as prevalent as the committee was led to believe.

But later in the afternoon, Dr. Robert Mecker, representing the Missouri chapter of the American College of Emergency Physicians, said gag rules are alive and well for several of his colleagues.

"They are the ones who have to provide the continuity of care and yes, they do have problems with the HMOs on a regular basis," he said.

In hearings this fall, committee members heard several health horror stories from physicians and patients about gag rules and their effect on health care. Of the three HMOs represented; Kaiser, Principal Health Care of Kansas City and St. Louis-based Cigna, none of them have gag rules written into their health plans, claimed their representatives.

However, they said they did have anti-disparaging clauses to prevent doctors from discussing the financial aspects of the HMOs. These clauses prevent a doctor from advising a patient on whether to join a specific managed care plan.

The managed-care representatives said complaints that had been voiced to the committee represented a small minority of an otherwise happy and content population.

And they warned that several of the committee's proposed recommendations might worsen health-care options for Missourians.

"In the big picture, any legislative actions by the General Assembly would not affect 60 percent of Missouri's insurance population," said Gerard Grimaldi, of the Kaiser-Permanente HMO.

The committee is in the final stages of a nearly six-month look at managed care in Missouri. Committee co-chairs Sen. Joe Maxwell, D-Mexico, and Rep. Tim Harlan, D-Columbia, said they hope to finalize a list of recommendations by the end of November.

A major point before the committee is coverage for emergency care.

For months, Maxwell and Harlan have held up letters from HMOs saying that broken bones were not considered medical emergencies for which the HMOs would provide emergency-room coverage.

When the HMO representatives told the committee that anyone in their plans could go to emergency rooms for such ailments, Rep. James Foley, D-St. Louis was incredulous. "I am amazed," he said. "What are you, the three angels of managed care?"

Mike Winters, a lobbyist for Missouri Managed Healthcare Association, told the committee that legally defining the term "emergency" or "medical necessity" like some members wanted could limit rather than help a patients options.

Previously, both Harlan and Maxwell said any recommendation would have a provision that include a "prudent layman's" definition of an emergency. That means if an average person would reasonably believe an emergency-room visit was warranted, then the HMO would be bound to cover the expenses.

None of the HMO representatives said they favored such a definition, saying they preferred to stick with judgments their company medical directors.