Legislators look to limit access to health care specialists with ‘gatekeeper’ law

Jan. 24--Two Missouri legislators have crafted bills that could allow many health insurance plans to limit consumers' access to specialty physicians.

The bills also would reduce consumer financial protections for people enrolled in health maintenance organizations, or HMOs.

The bills would allow insurers to add a "gatekeeper" provision that requires consumers to first see a primary care provider to obtain a referral before being able to see a specialist. That means a patient could be on the hook for the entire medical bill if he or she sees a specialist without a referral, according to health law experts.

Currently, Missouri law only allows closely regulated HMO plans to have gatekeepers.

Consumer advocates say the bills are worded so broadly that the gatekeeper restriction could be attached to any type of health insurance plan sold in the state, including a preferred provider organization, or PPO, the most dominant type of health plan used throughout the state.

"This is a big deal," said Sidney Watson, health law professor at St. Louis University's School of Law. "I also worry the way this is written that I may need a referral to go out of network."

The sponsors of the bills say the gatekeeper provision allows insurers to offer more attractive, lower-premium plans in exchange for a network that is more restrictive.

"I think the gatekeeper helps to keep the cost down, but I don't think it prevents anybody from going where they want to go," said Sen. Paul Wieland, R-Imperial, whose Senate Bill 911 includes the gatekeeper provision. He owns Wieland Insurance Group LLC, an insurance agency.

Rep. Don Gosen, R-Ballwin, who's sponsoring similar legislation through House Bill 2061, said he intends for the gatekeeper provision to be used only in exclusive provider organization, or EPO, plans.

In an EPO plan, patients can only go to in-network physicians and they have no option to go to an out-of-network provider.

"The intent is not to have it impact PPO plans," said Gosen, who also is a State Farm insurance agent.

He said if the language is too broad and has an "unintended consequence (then) we can get that fixed."

The Missouri Department of Insurance, Financial Institutions and Professional Registration declined to comment on the proposed legislation.

DRIVING DOWN COSTS

This gatekeeper restriction is the latest step to control access to certain providers in an effort to drive down costs.

"Nothing is getting cheaper," said Larry Case, executive vice president of Missouri Association of Insurance Agents. "Everybody is looking for cost savings these days."

EPOs first began operating in Missouri two years ago after legislation was approved in 2013. Illinois does not permit these types of plans to be sold.

Because of a narrow in-network, EPOs typically have lower premiums. But the plans have no regulations in place to protect patients from physician networks that may be inadequate, which worries consumer advocates.

HMOs offer very narrow networks and a gatekeeper restriction. But unlike an EPO, HMO plans have a myriad of consumer protection rules that govern their operations.

For example, HMOs must demonstrate to insurance regulators that the network is adequate. If the HMO doesn't provide a particular service, it must demonstrate that the consumer won't pay more because they're forced to go outside of the network.

If a gatekeeper won't refer a patient to a specialist, the HMO consumer has certain rights to appeal under state regulations.

Some insurers are now trying to turn EPOs into an HMO-style plan without the HMO regulations.

Last year, Missouri's top insurance regulator barred two EPO plans offered by UnitedHealth from operating in the state because of a gatekeeper provision that was included in those plans.

The regulator says only HMOs can have health plans with gatekeepers, but UnitedHealth is appealing the decision.

The proposed bills by Wieland and Gosen would eliminate this obstacle.

"We support legislation that would meet consumer demand for more affordable health plan options," UnitedHealth said in a statement to the Post-Dispatch.

FEWER PROTECTIONS

Watson and others fear the gatekeeper will create more hassle for consumers and more administrative costs.

"They are put in place by health plans to try and keep cost and utilization under control," Sabrina Corlette, project director at the Center on Health Insurance Reforms at Georgetown University, said of gatekeepers.

The gatekeeper idea was the hallmark idea of HMO plans, which became popular in the 1990s, she said. But there was a backlash against the plans because of the hurdles placed before patients trying to see an in-network specialist.

Some plans even required additional hurdles like prior authorization before being allowed to see a specialist. When the health plan denied care, some questioned whether the decisions were being made for financial reasons.

The backlash against HMOs led to the formation of PPO plans, Corlette said.

In addition, consumer advocates fear people will unknowingly pick these types of plans, not realizing the restrictions that come with it.

But Emily Bremer, a Clayton-based insurance broker, said the reality is more affordable options are needed. Some consumers are willing to trade in a broad network for a narrower one if the plan is less expensive.

"As much as they would love to have a big broad network with everybody in it, they just can't afford it," Bremer said. "There is a need for affordable options right now."

The bills also peel back some consumer protections for HMO plans and pass more costs onto the consumer.

One of the proposed provisions would allow copayments for certain services, such as physician office visits, to exceed 50 percent of the total cost of the service. This is currently capped at 50 percent.

While that may seem reasonable for an inexpensive bill, it raises questions about affordability when a patient gets a service with a hefty price tag.

"If your MRI (magnetic resonance imaging) is going to cost $4,000, they could theoretically charge the patient a copay of $3,000," said Jeff Howell, director of government relations for the Missouri State Medical Association, a group that represents physicians.

The group is adamantly opposed to the two bills.

Gosen said the copay provision is about ensuring HMOs can better compete with PPOs, or preferred provider organizations, that dominate the market in Missouri.

Howell said these bills are about furthering the interests of the insurance companies.

"These are bills introduced not to help patients or physicians but to help insurance companies," he said.

Samantha Liss -- 314-340-8017

@samanthann on Twitter

sliss@post-dispatch.com

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