Keep Health Care on List

Gov. Gray Davis has appropriately made education his top priority. Given growing anxieties throughout the state about managed care, however, the governor would be wise to make sure that his administration doesn’t lose sight of health care.

California’s health and safety codes require the state to ensure that health plans pay doctors enough money to treat patients adequately, to guarantee that medical decisions are rendered by qualified medical providers unhindered by fiscal constraints and to ensure that HMOs promptly deliver health care that is consistent with professional “best practice” standards.

With 42% of HMO patients recently reporting problems with their managed care provider, frustration has reached a record high. Physicians are equally upset, which is why the nation’s fastest-growing labor union earlier this week announced a national drive to organize physicians into alliances opposed to managed care. And even HMOs are frustrated with a state agency’s decision in January to impose an expensive and arbitrary mandate requiring Kaiser Permanente to cover Viagra.

Davis’ instinct to refrain from micromanaging HMOs is wise; for politicians tend to blunder when they try to wield scalpels on the problems of medical care. But the governor should not stand on the sidelines. Frustrations and bad solutions will grow if state oversight remains ineffective.

From the consumer standpoint, there are two key challenges facing HMO health care in California:

* Establishing third-party independent review of health plans, which should give patients the care they need when they need it. Patients who seek to appeal a health plan’s decision to deny them medical care should be guaranteed the right to a fair and speedy appeals process, one like the Texas Legislature enacted in 1997. While many California HMOs require patients to exhaust a lengthy internal appeals process before being allowed to appeal to outside reviewers, Texas allows patients to appeal to outside reviewers who resolve routine disputes within an average of 18 days and emergency cases within an average of nine days.

* Improving health care quality. Currently there are no agreed-on standards for measuring health care quality in the state. State regulators should begin working with medical, consumer and employer groups to gather comprehensive information about health care quality, identifying the health plans and medical treatments that foster health care in the most cost-effective ways and making that information public so that people can make informed decisions.

Davis should examine whether the current state oversight of HMOs meets the standards to which California should aspire. We would suggest it does not. As a first step toward providing a more responsive health care system, Davis should find a more effective way for California to exercise appropriate oversight. The current unresponsive oversight is a tiny part of the portfolio of the state’s Business, Transportation and Housing Agency. The Health and Human Services Department, which has extensive experience in handling consumer complaints and reviewing compliance with best practices, should instead be central to any oversight program.

California, a state in which the majority of workers are insured through managed care, should not be a laggard in finding effective ways to see that the industry it helped to pioneer remains a successful model of quality and cost-efficient health care.