Health Maintenance Organizations

Surging healthcare costs have prompted a return to some unpopular money-saving measures that were scaled back after the backlash against managed care during the late 1990s, according to a new study. Requirements such as referrals for specialists and pre- authorizations for some medical services are quietly reappearing in some health plans, according to the study, released Wednesday and published in the policy journal Health Affairs.

A state health agency is investigating whether there is a "systemic problem" with a doctor-owned group working for the insurance industry that has turned down numerous requests by other doctors here for pediatric specialty care for children, officials say. Investigators are looking to see if the rejections are based on legitimate medical disagreements or on a desire by the group to boost its profits by illegally holding down costs for health-maintenance organizations.

Some of the largest health maintenance organizations in California are drawing fire from minority activists for refusing to give state regulators information about services provided to patients who don't speak English. According to regulators, Blue Shield of California Inc., Cigna Healthcare of California Inc. and Aetna Inc. -- with a total of 3.4 million Golden State members -- declined to voluntarily submit the data to the Office of the Patient Advocate.

None of California's biggest health maintenance organizations excels at meeting all of the needs of its members, according to a "report card" released Thursday by the state's Office of the Patient Advocate. But HMOs and consumer advocates -- who rarely see eye to eye -- give the state's fourth annual survey poor grades for leaving out key information that could help people better choose a health plan. "It's not that we don't agree with the goal of providing ...

Two Southern California HMOs posted higher third-quarter earnings Wednesday, which PacifiCare Health Systems Inc. and Molina Healthcare Inc. separately credited in part to a flood of new members. Shares of PacifiCare, the biggest manager of U.S. Medicare health plans, rose 19% after third-quarter earnings beat analysts' estimates and the company raised its 2004 forecast. Shares of most healthcare companies rallied Wednesday because of President Bush's reelection.

Long before it ended up attached to a budget bill being voted on by Congress, the effort to ease legal requirements to provide abortion services was underway in community hospitals across the country. The omnibus spending bill approved Saturday by the House and Senate contains a provision that will allow hospitals and health maintenance organizations to refrain from providing abortions and related services. President Bush is expected to sign it into law.

Congress is expected to debate health-care reform -- again -- this year, but the Supreme Court is set to decide two crucial issues: whether drug makers can be forced to give lower prices to the uninsured, and whether HMOs can be forced to allow patients to use their favorite doctors. In both areas, states have pressed ahead with pro-consumer measures while debate in Washington has stalled. But this month, industry lawyers will urge the high court to block the new state reforms.

A lawyer for the managed care industry ran into skeptical questioning from the Supreme Court justices Tuesday in a key test case for state-led health-care reforms. Kentucky and 24 other states require health maintenance organizations to open their networks to outside doctors, hospitals and pharmacists as long as these "service providers" agree to abide by the rules of the network. These laws were passed as part of a "patients' bill of rights" in several states.

Kaiser Permanente, the largest HMO in California, announced a $1.8-billion plan Tuesday to computerize patient medical records. The three-year project will affect 8.4 million members in nine states, including 6.3 million in California. It marks a significant milestone in the health-care industry's push to catch up with other industries by switching from paper to computer records. Under the automated system devised by Epic Systems Corp.

In a victory for patients and their doctors, the Supreme Court ruled Wednesday that health maintenance organizations can be forced by state law to open their networks to outside doctors and hospitals. The unanimous decision upholds so-called willing provider laws in half the states, but not California, which does not have such a law. These pro-consumer statutes permit patients enrolled in an HMO to see a favorite doctor or specialist, even if the physician is not part of the network.