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Show The ability of managed care insurance plans to provide accessible rural health services has been discussed by the Rural Health Technical Advisory group, the Utah Health Policy Commission (Commission), and the Utah Legislature. The Utah Health System Improvement Act. This act was passed by the 1995 Utah Legislature. Part of the act, which contains Governor Michael O. Leavitt's second year health reform legislation, addresses the issue. The law states the Department of Health (DOH): shall monitor and report to the Health Policy Commission ... on the development of managed health care plans in rural areas of the state, including the effect of managed health care plans in frontier areas of the state, any consequences such plans have on the cost of medical care, and access to health care providers in rural/ frontier areas of the state (Utah Code Annotated Section 63C-3-104 (2)(e)). Essentially, this program provides for a one year study on the impact of managed care in rural areas. It is also an opportunity for insurance companies with managed care plans to voluntarily participate in solving problems that managed care could create in Utah's rural areas. What Does 'Managed Care* Mean? It is a complex issue. For example, depending on the way a managed care plan is set up, providers and clients are at varying levels of financial risk. For some, a referral to a specialist by a primary care physician is necessary. Primary care providers often function as health care coordinators or gatekeepers. For this study DOH defines managed care as medical care paid for by insurance which channels patients to a preestablished list of providers, but which may permit care to be provided by providers who are not on a pre-approved provider list at additional out-of-pocket cost. Not everyone was satisfied with the one year's study solution. Some favored immediate action in the form of legislation mandating some type of an "any willing provider" (AWP) provision for rural/frontier areas of the state. Others were not sure that an AWP provision would solve the problem. However, an AWP provision is not the panacea that some would like it to be. Defining all the nuances and writing a law that "fixes" the problem without unintended consequences is most difficult. What Does AWP Mean? An AWP provision could compel insurers to contract with any provider who agrees to abide by the terms of their contracts and to accept their payment levels. It allows patients to choose health care providers outside their managed care insurance plan, and it requires the plan to reimburse those doctors, hospitals, clinics, pharmacies, etc., for their services. Also, nationally existing and proposed AWP provisions vary considerably de- pending on what values are being promoted or what problem they are trying to solve. In Utah, one key issue is geography. A recently debated proposal was to have an AWP option for patients who would otherwise have to travel more than 30 miles from their home or work to get to the closest approved healthcare provider. Such patients would be allowed to choose a provider who is closer and their insurance plan would reimburse that provider under a "preferred provider contract," as long as the fees charged did not exceed those outlined in the in-sureFs plan. Other Factors to Consider When Addressing the Need for AWP Provisions. A wide range of opinion exists on the value of an AWP provision and whether or not it would be able to solve the problem. Some of these opinions are included in the article, "Should Utah Have an 'Any Willing Provider1 Provision for Health Care? A Range of Opinions" in Utah Health Care Delivery (Vol. V, Winter 1995; jointly published by the Bureau of Primary Care and Rural Health Systems (BPCRHS) and the Association for Utah Community Health). A reprint of the article may be obtained from BPCRHS. There was consensus among those interviewed that little need exists for an "any willing provider" law in Utah's urban areas and that urban areas are better served by competition among multiple health care sources. However, in rural/frontier areas there are not enough available health care providers to make competition effective. Many third party payers are concerned that an AWP provision designed for rural/ frontier areas could eventually turn into a statewide AWP mandate. David Gessel (Vice President for Governmental Relations and Legal Affairs, Utah Association of Health Care Providers) suggests any state AWP law would be preempted by ERISA federal legislation prohibiting states from passing laws that regulate health plans (either self-insured or contracted) for companies with more than 50 employees. Thus, a state AWP provision would regulate only plans for smaller employers. Mr. Gessel estimates that 50 percent of rural employers and their employees would be exempt from complying with a state AWP law because of ERISA. What Is DOH Doing to Monitor the Impact of Managed Care in Rural Areas of Utah? The Commission needs to know what is working and what is not working. It is open to ideas about how to improve the situation. In addition to the article in Utah Health Care Delivery, education efforts have included flyers, letters to the editor, a press release, an article in HealthNotes, letters to associations concerned about health care issues, to legislators, mayors, city councils, etc. Utah's Health: An Annual Review 1995 137 |