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August 6, 1999
Lobbying efforts by local APA members paid off handsomely this legislative session with an antitrust reform provision in Texas allowing doctors to negotiate managed care contracts, a parity bill in Connecticut, and a comprehensive parity bill for serious mental illnesses in Louisiana.
In June Texas became the first state in the nation to enact an antitrust reform law allowing psychiatrists and other physicians to band together to negotiate the terms of their contracts with health plans and managed care companies without the threat of antitrust violation.
Katherine Becker, deputy director of state affairs in APA's Division of Government Relations, told Psychiatric News, "The Texas Medical Association (TMA) is defining the state debate on patient protection with its 1999 success on joint negotiation as it did in 1997 with the managed care liability law. TMA's aggressive efforts will not only benefit patients in Texas, but they will have an indirect positive impact in other states, as the scope of permissible patient protection legislation has broadened."
The Texas Society of Psychiatric Physicians (TSPP) supported TMA in its successful legislative efforts to correct the unfair practices of some managed care organizations, the most notable being the antitrust reform bill, according to TSPP President Jefferson Nelson, M.D.
The patient protection law, which goes into effect next month, allows physicians as a group to negotiate their fees and prices for services directly with a health plan, if the state's attorney general determines that the plan has "substantial market power." That will be decided based on whether the quality and availability of patient care are adversely affected by the health plan, according to Becker. The state attorney general would also supervise physician negotiations with health plans.
In addition to fees, physicians can negotiate payment conversion factors in an RBRVS or similar reimbursement methodology, the amount of any discount on the price of their services, and the dollar amount of capitation of fixed payment for services rendered by them, noted Becker. However, physicians are prohibited from initiating strikes, boycotts, or reductions of health care services.
TMA President Alan Baum, M.D., commented in a press release last month, "This significant new law, which passed both houses of the legislature by overwhelming margins, allows physicians especially in solo or group practices to communicate with each other and jointly negotiate with HMOs. Without this basic right, independent physicians are powerless to challenge the investor-driven HMOs that offer take-it-or-leave it contracts full of anti-patient provisions."
Baum continued, "State intervention has become imperative to assure patients' legitimate rights that the health care they've already paid for is delivered as promised."
There are no conditions on physicians negotiating health plan practices and procedures to assess and improve the delivery of preventive health care services, women's medical and health care, and the early detection and management of diseases in children.
Physicians can also join together to negotiate clinical criteria for cost-efficient disease management programs, clinical practice guidelines and coverage criteria, and administrative procedures including methods and timing of physician payment for services, according to Becker.
Patient protection legislation took a new twist in Connecticut recently by including a comprehensive parity provision for mental health and substance abuse coverage. The bill passed the legislature in June and was signed by Governor John Rowland (R) last month, making Connecticut the 24th state with a parity law.
Becker commented to Psychiatric News, "With assistance from the Connecticut Psychiatric Society [CPS], the driving force behind this legislation is one of the country's outstanding leaders, Senate President Pro Tem Kevin Sullivan [D]."
Sullivan, who has acknowledged that his wife suffers from clinical depression, marshaled the bill through the Senate and secured the cooperation and endorsements of key House leaders, according to CPS lobbyist Jacquelyn Coleman.
The bill significantly expands a 1997 parity law to mandate benefits for the diagnosis and treatment for all mental disorders or conditions defined in the DSM-IV. The previous parity law applied to about seven serious mental illnesses, according to Coleman.
To allay legislators' concerns that the parity legislation would cover "anything and everything" listed in the DSM-IV, CPS agreed to exclude mental retardation, learning disorders, motor skills disorder, communication disorders, caffeine-related disorders, relational problems, and additional conditions that may be a focus of clinical attention and otherwise not defined as mental disorders in the DSM-IV, according to CPS state legislative representative Harold Schwartz, M.D.
The law states that benefits will be paid to all facilities providing psychiatric services and to psychiatrists, mental health professionals, family and marriage counselors, and alcohol and drug counselors.
Parity legislation in Louisiana also took a giant leap forward this session. Last month Governor Michael Foster (R) signed the most expansive serious mental illness bill in the nation, making it the 23rd state with a parity law, according to Dudley Stewart, M.D., Louisiana district branch legislative representative.
"The law will benefit adults and children with serious mental disorders who in the past have had inadequate health insurance coverage," said Stewart.
The 13 serious mental illnesses covered by the legislation are schizophrenia, schizoaffective disorder, pervasive developmental disorder/autism, panic disorder, obsessive-compulsive disorder, major depression, anorexia, bulimia, Asperger's disorder, intermittent explosive disorder, posttraumatic stress disorder, psychosis NOS in individuals under age 17, Rett's disorder, and Tourette's disorder, according to Stewart.
Insurers will be required to provide 45 inpatient days and 52 outpatient visits per calendar year, which includes partial hospitalization for patients with the 13 named mental disorders.
Parity gained momentum in the legislature after a joint House and Senate health insurance committee sponsored a study on mental health coverage in the early 1990s, showing that parity was cost-effective.
Rep. James Donelon (R), who chaired that committee, has become a staunch supporter of parity for serious mental illnesses and has introduced a limited version of the current law every session for the last four years.
The bills failed to pass because of strong opposition from the Louisiana Coalition of Business and Health, which is opposing the current bill, noted Stewart.
"What made the difference this session was greater bipartisan support and a tremendous lobbying effort by a coalition made up of the Louisiana Psychiatric Medical Association, Louisiana Chapter of the Mental Health America, Louisiana State Medical Society, Louisiana Chapter of the National Alliance on Mental Illness, Louisiana Chapter of the National Association of Social Workers, the Louisiana Counseling Association, and the Louisiana Psychological Association."
Stewart also credited APA's Office of District Branch and State Society Relations with providing the Louisiana Psychiatric Medical Association a grant to expand its lobbying efforts on parity and the psychologists prescribing bill, which was defeated recently.
More information on the Texas bill is found by going to the Web site www.capitol.state.tx.us/tlo/billnbr.htm and entering SB 1468. More information on the Connecticut parity bill, Public Act #99-284, is found at www.cga.state.ct.us/ps99/Act/pa/1999PA-00284-R00HB-07032-PA.htm. Information on the Louisiana parity bill is found at www2.legis.state.la.us:88/CVT2/OUT/0000FRSM.pdf. Acrobat Reader is needed to view the Louisiana bill.-C.L.