Terms of California Reform Debate Clearer as Sides Develop Want Lists

California Gov. Pete Wilson and legislative leaders of both political parties have defined what they want in managed care reform legislation. All agree on the need to expand enrollees' rights to appeal coverage denials.

Rather than endorse specific pending bills or proposals of a managed care reform task force that completed its work earlier this year, Wilson said any reform legislation must meet three conditions: It must safeguard or improve quality of care, should not diminish access and should be fiscally prudent and "not impose mandates that would bankrupt our health care system."

To achieve those goals, Wilson would create a new state body to oversee managed care and gather and publish standardized outcomes data. Wilson would support legislation that enhances continuity of care; addresses concerns about utilization review; requires public disclosure of formularies; improves methods of informing consumers about the results and effectiveness of treatments; gives physicians, in consultation with patients, full authority over the length of post-mastectomy hospital stays, and expands access to specialists, such as obstetrician/gynecologists. He endorses mandatory coverage of contraception, except by employers or organizations that object on religious or conscientious grounds. The governor did not address the issue of whether health plans should be liable for medical malpractice.

Wilson called on the legislature to ensure that health plans and medical groups fully disclose grievance procedures and help patients to appeal decisions and file grievances. The governor said he would support legislation requiring plans to cover second medical opinions and create independent third-party review processes for coverage denials.

Assembly Republicans proposed a series of bills that they say follows the outline of the governor's recommendations. The GOP plan would create a Department of Health Care Oversight. Unlike Democratic proposals, Republicans would not mandate coverage of specific conditions.

Assembly Democratic leaders who drafted the Family Health Care Rights Act say their proposals would require California HMOs to uphold five rights of members: the right to choose a doctor, receive appropriate treatment, get information about benefits, obtain emergency care and be assured of confidentiality.

Early compromises could come on the issues of second opinions and external review.

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