I. INTRODUCTION AND OVERVIEW
A. HJR 560'S SCOPE AND BACKGROUND.
HJR 560 approved by the 1995 Session of the Virginia General Assembly established a joint subcommittee to "study women's access to obstetrical and gynecological services, particularly in managed care plans." The subcommittee was directed to make recommendations on "how duplicative costs and administrative snarls can be avoided." The resolution (Appendix A) was patroned by Delegate Gladys Keating who also served as the subcommittee's chairman. The nine-member joint subcommittee consisted of: Delegates Joyce K. Crouch of Lynchburg, George H. Heilig, Jr. of Norfolk, Gladys B. Keating of Fairfax, Kenneth R. Plum of Fairfax, and Lacey E. Putney of Bedford, all appointed by the Speaker of the House of Delegates; and Senators Clarence A. Holland of Virginia Beach, Yvonne B. Miller of Norfolk, H. Russell Potts, Jr. of Winchester and W. Henry Maxwell of Newport News who served as vice-chairman, all appointed by the Senate Committee on Privileges and Elections.
A related study resolution (HJR 52) was passed by the 1994 Session, requesting the Secretary of Health and Human Resources ("the Secretary") to consider whether legislative or administrative action should be taken to require health insurers and other health care coverage plans to designate obstetricians/gynecologists as "primary care physicians," or "PCPs" within managed care plans. PCPs serve a "gatekeeper" role in health care coverage plans employing managed care structures, coordinating the medical care and treatment of designated patients.
The Secretary's report (House Document 24 of 1995) found that there was no consensus on the PCP designation issue within the medical community. The report also indicated that Ob/Gyns are included in some managed care plans' PCP panels, and that access to Ob/Gyns, without referral, for annual gynecological examinations was then permitted to some extent.
The Secretary concluded that no legislative or other action was warranted on the issue at that time, stating that the PCP issue was one "best addressed by market forces." The report went on to suggest, however, that (i) Ob/Gyns be surveyed on this general issue to obtain a consensus on the PCP issue and (ii) further study was indicated to determine the overall need for Ob/Gyn access.
B. PERTINENT LAW IN VIRGINIA AND IN OTHER STATES.
The study's overarching issue was PCP coordination of patient access to Ob/Gyns. Except to the extent Ob/Gyns are designated as PCPs within such plans (when such designation is permitted), they are specialists. As such, some managed care plans require that Ob/Gyn patient visits, examinations and treatments covered by such plans be coordinated by PCPs. Failure to do so may result in a patient paying more out-of-pocket than for a visit or treatment coordinated through her PCP.
Currently, Virginia law is silent on the access issue. The Code of Virginia's insurance title (38.2) contains no express provision governing the reimbursement of Ob/Gyns in managed care plans, generally, or patient self-referral to Ob/Gyns in particular. Thus, Ob/Gyn access is dictated by market forces, and, as discussed in the Secretary's 1995 report, the degree of access varies somewhat from plan to plan.
In some other states, however, Ob/Gyn access has been addressed. In North Carolina, for example, a 1995 bill directed HMOs, PPOs (preferred provider organizations) and other managed care-style plans to permit unrestricted "direct access" to in-network Ob/Gyns (Appendix B). The legislation, effective January 1, 1996, places no limitations on the number of self-referred visits and includes "the full scope of medically necessary services provided by the participating Ob/Gyn in the care of or related to the female reproductive system and breasts." Services covered include the services of nurse practitioners, physician's assistants, and certified nurse midwives in collaboration with Ob/Gyns. Coverage is limited, however, to the benefits provided in the pertinent health care plan.
Maryland addressed this issue in its 1992 and 1994 Sessions (Appendix C). Under Maryland law, managed care plans have two options: (i) permit covered individuals to designate Ob/Gyns as PCPs, or (ii) permit covered individuals one self-referred annual visit to in-network Ob/Gyns for routine gynecological care. Louisiana enacted legislation in its 1995 Session (Appendix D) authorizing PCP designation for Ob/Gyns, and also permitting direct access for one annual visit, with a second direct access visit permitted if medically indicated. Direct access is principally limited to in-network providers, and the managed care plan may require consultation between the provider and the patient's PCP.
A Connecticut law (Appendix E) enacted in 1995 is similar to the Maryland and Louisiana laws. It permits direct access to in-network Ob/Gyns for primary and preventive obstetric and gynecological services. There are no restrictions on the number of covered visits. The Connecticut law also permits an individual to designate an in-network Ob/Gyn as her PCP, and any other in-network physician as an additional PCP. The statute permits managed care plans to require Ob/Gyn consultation with PCPs to discuss proposed services and treatment plans.
A 1994 New York enactment (Appendix F) requires HMOs to permit direct access to an in-network "qualified provider" of primary and preventive obstetrical and gynecological services. Such access, however, is limited to two annual examinations, and to care related to any pregnancy. Further direct access is permitted for any additional services or treatment required as a result of the examinations or acute gynecological conditions. The HMO may, however, require the provider to discuss any proposed treatment plan or services with the individual's PCP.
Other states which have legislated in this area include the State of Washington which acted in its 1995 Session to require Ob/Gyns' designation as PCPs (Appendix G). Similar PCP-designation legislation passed the Florida Legislature in its 1995 Session (Appendix H), and in California in 1994 (Appendix I). A 1995 Mississippi bill (Appendix J) is silent on the PCP designation issue, while permitting direct access to in-network Ob/Gyns.
From these bills, a number of legislative models emerge. They are summarized in the chart found on pages 3 and 4 of this report.
The key variables within these enactments are: (i) PCP designation, (ii) limited versus unlimited direct access, (iii) extent of service authorized where direct access permitted, (iv) whether consultation is required between PCP and Ob/Gyns, and (v) whether providers other than Ob/Gyns, e.g., nurse practitioners and other providers of obstetrical and gynecological care are included in any direct access provision.
II. THE SUBCOMMITTEE'S WORK
The joint subcommittee used its first meeting to determine the study's focus. This was accomplished in large part by receiving testimony from the Ob/Gyn community on the access issue, and also by receiving testimony on the access issue from other providers, such as family physicians. Additionally, managed care plan representatives summarized their views concerning Ob/Gyn access within managed care structures.
The joint subcommittee's second meeting featured a public hearing and a work session. Speakers at the public hearing included Ob/Gyns, family practice physicians, managed care plans, women receiving their obstetrical and gynecological care through managed care plans and representative of the business community. The joint subcommittee used its work session to focus on information received at the public hearing, and on the access legislation enacted in other states.
In its final two meetings, the joint subcommittee focused on two legislative models--those of Maryland and North Carolina--and a resolution to continue the study in 1996.
A. VIEW OF THE OB/GYN COMMUNITY
Representatives of the Virginia Obstetrical and Gynecological Society told the subcommittee that managed care plan structures have, in their view, negatively affected the quality and availability of obstetrical and gynecological care afforded women covered under such plans -- particularly in the area of gynecological care. In many such plans, women must be formally referred by their PCP (who are typically internists, family practice physicians, or general practitioners) to an Ob/Gyn before reimbursement for the latter's services will be approved. Since most plans do not permit Ob/Gyns to be designated as PCPs, women covered under these plans must coordinate their visits to an Ob/Gyn through a non-Ob/Gyn PCP.
Ob/Gyn representatives also told the subcommittee that PCP coordination may delay treatment when PCPs require an office visit before authorizing a referral. This results in inconvenience to female patients and in duplicative medical expenses. Additionally, some PCPs prefer to treat certain gynecological conditions or to perform certain screening tests (e.g., pap smears), instead of referring patients to an Ob/Gyn for these services. One public hearing witness suggested that PCPs may be disinclined to refer because of PCP contract terms penalizing them for excess referrals. One Ob/Gyn also told the subcommittee that while some plans permit Ob/Gyn direct access for annual "wellness" examinations, virtually all follow-up treatments must typically be approved by the patient's PCP.
Ob/Gyn representatives said that a non-Ob/Gyn PCP who treats a female patient's gynecological condition instead of referring her to an Ob/Gyn, may lack the education, training or experience necessary to fully assess the condition and its potential complications. An Ob/Gyn who testified at the subcommittee's public hearing said that several of her patients had gynecological conditions that were improperly diagnosed or treated by non-Ob/Gyn PCPs. A summary of these cases is attached as Appendix K.
Ob/Gyns also spoke to the relationship of trust that is established between women and their Ob/Gyns. For many women in their reproductive years, Ob/Gyns are the only physicians many of them see regularly. Consequently, the interposition of PCP gatekeeping mechanisms, Ob/Gyns said, disrupts these relationships and may ultimately affect women's gynecological health. A representative of the Virginia League for Planned Parenthood supported that viewpoint, stating that particularly in the area of pregnancy prevention and sexually transmitted diseases, the continuity of relationships between women and their Ob/Gyns is central to diagnosis and treatment.
A September 1995 survey of Virginia's Ob/Gyns conducted by the Virginia Ob/Gyn Society and the Virginia section of the American College of Obstetrics and Gynecology showed that ninety percent of respondents' greatest concern for their patients was direct access, while only ten percent said their greatest concern was having primary care provider status. Ninety-nine percent of respondents said they would support legislation allowing direct access to Ob/Gyns in managed care plans. A report of the survey is attached as Appendix L.
Ob/Gyns, Ob/Gyn nurse practitioners, and Certified Nurse Midwives urged Virginia's adoption of legislation patterned after the North Carolina law permitting unrestricted access by women to in-network Ob/Gyn providers within their managed care plans.
B. VIEWPOINT OF MANAGED CARE PLAN REPRESENTATIVES.
The Virginia Association of HMOs ("the Association") took the lead in presenting the viewpoint of managed care plans on the access issue. Their view is that PCP coordination of women's health care, including oversight of referrals to specialist such as Ob/Gyns, is professionally appropriate while affording cost-moderating benefits. And, this system compares favorably to the conventional fee-for-service (FFS) plans in which patients select providers at will. According to the Association, between 1988 and 1993, HMO premiums increased forty percent less than premiums for FFS plans, while providing more comprehensive benefits and lower out-of-pocket costs.
The Association also stated that HMOs provide women better access to preventive care than traditional FFS plans. According to a Health Care Financing Authority (HCFA) study of Medicare HMOs cited by the Association, almost 60 percent of HMO patients diagnosed with cervical cancer were diagnosed at the earliest stages as compared to thirty-nine percent of FFS patients. Moreover, a Center for Disease Control and Prevention report showed that the percentage of women age 50 and older receiving cancer screening, including mammograms, CBE and pap tests was higher in women in HMOs compared to FFS patients. The Association also stated that HMOs are much more likely to offer coverage for contraceptive and infertility services than conventional insured plans.
Managed care plans are currently providing limited direct access to Ob/Gyns in many managed care plans. The Association surveyed its HMO members in conjunction with this study to determine the extent of Ob/Gyn access. As of November 1995 there were twenty-five HMOs licensed by the State Corporation Commission's Bureau of Insurance. Of twenty-three plans responding to the survey, twenty-one indicated that self-referral to an in-network Ob/Gyn was allowed. Sixteen of the twenty-one limited such self-referrals to an annual well-woman visit, while five plans placed no limits on the number of self-referrals. The remaining two plans responding to the survey permitted Ob/Gyns to be designated as PCPs. A report of the survey is attached as Appendix M.
A representative of Trigon Blue Cross Blue Shield emphasized that the core assumption of managed care is that the quality of care is enhanced by each patient having a physician familiar with all aspects of their care. Trigon does not permit Ob/Gyns to be PCPs within its managed care groups. Its standard HMO and point of service products use pediatricians, internists, family practitioners and general practitioners as primary care physicians. Trigon's standard policies cover, without referral, one visit per year to an Ob/Gyn for screening and preventive services. Necessary follow-up may be authorized by telephone without the necessity of an office visit with the PCP.
Overall, representatives of the Virginia Association of HMOs, Trigon Blue Cross Blue Shield of Virginia, Kaiser Permanente, and Humana, maintained that Virginia's current market-driven approach to the Ob/Gyn Access issue is appropriate and desirable. And, they emphasized that PCPs are capable of coordinating women's care and making Ob/Gyn referrals as and when appropriate.
C. VIEWPOINT OF FAMILY PRACTITIONERS.
The Virginia Academy of Family Physicians presented the viewpoint of generalists most often called upon to serve PCPs in managed care plans. Academy representatives told the subcommittee that family practitioners are currently the most broadly trained physicians in the United States. In addition to their undergraduate and medical school education, family practice specialists must complete a three-year residency program and sit for a certification examination administered by-the American Board of Family Practice.
The residency program provides training in a broad spectrum of obstetrical and gynecological conditions. Family practice residents are trained in providing prenatal care (including performing ultrasound studies to ensure fetal well-being) and performing routine vaginal deliveries. Additionally, residents learn to evaluate pap smears, perform endometrial biopsies to detect abnormalities of the uterus, and to perform fine-needle aspiration biopsies of breast lumps to diagnose breast cancer, and to perform numerous other procedures.
Family practice specialists also testified that their education and training prepares them to treat women for problems such as diabetes, hypertension, heart disease and a host of other medical problems. Family practitioners typically manage, without referral or consultation with a sub-specialist, over ninety percent of the medical problems they confront. In contrast, family practice representatives said, whenever a woman uses her Ob/Gyn for primary care, she will be referred to a specialist for whichever system is causing a medical problem. Thus, from a continuity of service and a cost point of view, the family practice physician is the specialty of choice for a primary care provider, they stated. An overview of family practice education and training is attached as Appendix N.
D. VIEWPOINT OF THE BUSINESS COMMUNITY.
Representatives of Virginia's business community, led by the Virginia Chamber of Commerce on behalf of Virginians for Health Care Solutions (a coalition of associations, businesses and health care companies), expressed their firm opposition to any statutory authorization for unlimited direct access or any requirement that managed care plans be required to designate Ob/Gyns as PCPs. The Chamber and the Commonwealth Coalition on Health emphasized that employers have chosen managed care because it delivers value in price and quality.
III. SUBCOMMITTEE FINDINGS AND RECOMMENDATIONS
The subcommittee concluded that managed care is modifying patients' use of specialists and sub-specialists such as Ob/Gyns who, in many cases, can be accessed only after consultation with generalist PCPs. Access is a critical issue to Ob/Gyns as evident from the Virginia Ob/Gyn Society/ACOG survey which identified this as the most important issue to them in terms of patient care. The issue, however, is equally important to providers of managed care plans seeking to strike a balance between quality health care and creating an affordable, competitive product.
As a legislative study committee, the subcommittee was unable to determine in absolute terms whether the quality of women's obstetrical and gynecological care in Virginia has been significantly affected by managed care's PCP gatekeeping mechanisms. Nor was it possible to determine what effect pro-access legislation recently enacted in North Carolina, Connecticut and other states has had on the quality and cost of such care in those states. However, the testimony and documentation submitted to the subcommittee underscores the Ob/Gyn access issue's importance to the future of reimbursed health care delivery within the Commonwealth.
During joint subcommittee work sessions at both meetings, Ob/Gyn access legislation from other states, including Connecticut, New York, North Carolina and Maryland was discussed. At the December 12 meeting, joint subcommittee members concluded that legislative study of Ob/Gyn access in managed care plans should continue in 1996. Members present at the December 12 meeting further agreed that in conjunction with reviewing the draft of its final report, joint subcommittee members would examine three legislative drafts separately incorporating: (i) the North Carolina legislative model permitting unrestricted access (Appendix 0), (ii) the Maryland model permitting one self-referred Ob/Gyn visit, or Ob/Gyn PCP designation (Appendix P), and (iii) a proposal permitting unrestricted access under the Maryland model if an individual's PCP is not a Family Practitioner (Appendix Q).
The joint subcommittee held its final meeting on January 11. It received the written comments on the final report draft from subcommittee member, Senator Clarence A. Holland (Appendix R). It approved a proposed study resolution continuing the study of the HJR 560 issues in 1996 (Appendix S) and approved the joint subcommittee's final report.
