Managed Care and Health Insurance State Laws for Ombudsman, Report Cards and Provider Profiles
Reviewed and revised May 2011
A trend begun about year 2000 within the larger HMO and managed care policy debate focused on provisions to make managed care work better. (See the State Legislatures magazine article "Making the Best of Managed Care" published June 2001.) Four types of laws emerged that particularly fit the theme "making it work." The legislation examined include:
- Ombudsman or consumer assistance offices - State-funded but independent offices that act directly on behalf of a patient unable to get needed medical care or other services.
- Consumer report cards - Widely published, easy-to-read reports that compare all the major competing managed care health companies for quality, finances and services. See Rand Study, 2006
- Provider and doctor profiles - Easy to get public records with details about doctors so consumers can spot strengths such as training and credentials as well as cautions such as medical board sanctions or malpractice judgments. This approach has been widely adopted by individual Medical Boards, in many cases without legislative or regulatory requirements. Most programs apply to all situations, not just those related to managed care or insurers.
- Right to a second medical or surgical opinion - Nine states formally mandate the option to obtain a second opinion, with costs covered by insurance. These states are CA, MD, MN, MO, NJ, NY, RI, WV & WI.
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Several states provide the general public with updated examples of evaluations, report cards and performance measures:
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The table below provides selected details about states that have laws and/or programs intended to provide direct information and assistance to enrollees in health maintenance organizations (HMOs) and related forms of managed care. Where available, a web link to the state's information is included. Please note that details of program structure and information vary substantially from state to state. Some enacted laws may not actually be implemented as of the date of this compilation. In some cases the programs have been established without legislation, and are so noted. No new laws were enacted in 2003-05.
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logo: CA DMHC
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Note: law citations in blue are web links; (parentheses) indicate annual bill numbers. (Statute citations are updated through 2006)
* Although MN does not have legislation requiring the state to report managed care performance, the state does produce a report under Minnesota Statues § 62D.08, which requires managed care organizations to provide information to the state.
| Examples of state program web resources: |
Additional State Medical Board Public Databases - links revised 6/05. (generally not initiated by state laws) |
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NCSL Resources:
"Managed Care State Laws and Regulations, Including Consumer and Provider Protections" - NCSL, updated 2008.
"State Legislation Relating to Disclosure of Hospital and Health Charges" - NCSL, updated December 2010.
Children's Ombudsman Offices NCSL Children Youth and Families Program reports operational offices in about 28 states. (updated February 2008)
Other Resources:
Surgeons, But Not Patients, Paying Attention To NY State CABG (Coronary Bypass) Report Cards - Heart patients who pick a top-performing hospital or surgeon are half as likely to die as those who pick a poor-scoring provider, Health Affairs, May-June 2006.
Will Physician-Level Measures of Clinical Performance Be Used in Medical Malpractice Litigation? - JAMA 4/19/06 as summarized by Commonwealth Fund, 5/06
"Methods commonly used to create medical “report cards” may Overstate the Quality of Health Care" - Rand Corp., 2/23/06.
"To Find a Doctor, Mine the Data" - article in New York Times, 9/22/05 [requires user registration]
Quality Ratings Have Small Impact on Consumer Decisions - Harris poll shows 22% view HMO ratings - October 2002.
DocFinder- A central link clearinghouse for state physician profiles and reports, by Administrators in Medicine (AIM), 2005. They cite 103 million consumer inquiries on their websites.
Consumer Health Care Decision Support: State of the Art - A discussion of private employer activities, by National Health Care Purchasing Institute, July 2001.
"The Place for Public Documents: On File or Online?" - New York Times, March 19, 2002. The article noted that 7.4 million people visited the Massachusetts MD database since 1996.
Author: Richard Cauchi covers health insurance and managed care issues for NCSL. Steven Landess provided additional research and updates in May 2011.
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