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Managed Care Ombudsman, Report Cards and Profiles,

 

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:

  1. 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.
  2. 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
  3. 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. 
  4. 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. 

Several states provide the general public with updated examples of evaluations, report cards and performance measures:

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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Note: law citations in blue are web links; (parentheses) indicate annual bill numbers. (Statute citations are updated through 2006)

State

Ombudsman - 17

Report Cards - 28

Provider Profiles

AL

.

.

AL - without legislation
AL Medical License search [2011]

AK  .  . AK - without legislation
AK professional license search: State agency web site [2011]

AZ

.

.

2000 law: Ariz. Rev. Stat. § 2-1403.01 | Arizona Medical Profiles [2011]

AR  .  . AR - without legislation
AR license verifications: State Medical Board web site [2011]

CA

2000 law: Cal. Health & Safety Code, part 1.86 sec. 444.20 (AB 2327);
1999 law: (AB 78) Chapter 525

2000 law: Cal. Health and Safety Code § 1382

2000 law: Cal. Health & Safety Code, part 1.86 sec. 444.20 (AB 2327)  |
California Medical Profiles [2011] 

CO

CO - without legislation
> Dept. of Insurance publications || Small Group Insurance Premiums Comparison Guide [2009]

CO - without legislation

CO law HB1331 - 2007 ; §37-53
Colorado Doc Profiles [2011]
CT

1999 law: Conn. Gen. Stat. § 38a-1041;

1995 law: Conn. Gen. Stat. § 38a-478a

Conn. Gen. Stat § 20-13j;
CT Physician Profiles
 |
CT MD license status | [2011]
DE  .  . DE - without legislation.
DE professional license lookup: State agency web site [2011]
DC DC - without legislation
DC health professional licensing lookup: District Dept. of Health web site [2011]

FL

1996 law:
Fla. Stat. § 641.60 ;
2000 law:
Fla. Stat. § 408.7056

1997 law:
Fla. Stat. § 641.51(9)

1998 & 2000:
Fla. Stat. § 455.5651

Florida Medical Profiles | Osteopathic |

License profiles [2011]

GA

1999 law:
Ga. Code § 33-57-1

 

 

Georgia Profiles without legislation [offline 11/2010]

HI     HI - without legislation
HI Professional and Vocational Licensing

ID

 

 

 

1998 law:
Idaho Code § 54-4603 |
ID Patient Freedom of Information Database [2011]

IL

1999 law: Public Act 91-0617 (S 251, see § 90)

 

 

Doc License Lookup
without legislation

 [2011]
IN  .  .  IN - without legislation
Doc Finder [2011] 

IA

 

 

1999 law: Iowa Code sec. 415K 1.2 (S.276)

IA - without legislation
IA DocFinder [2011]

KS

 

KS - without legislation

KS - without legislation
Kansas Physician search [2011]

KY

KY - without legislation
2008 update:  Kentucky has a Medical Insurance Ombudsman for retired state employees:

 

 

KY- without legislation
KY Physician Profiles [2011]

LA

 

 

1998 law: La. Rev. Stat. Ann. 40:1300.71

LA Without legislation
Louisiana Physician profiles [2011]

ME

1998 law: Chapter 792 of 1998

 

 

ME - without legislation
Maine Doc Profiles | Maine Osteo [2011]

MD

1999 law: (H 182)

1997 law: Md. Code Ann. Health Gen. I § 19-1508(c)

1999 law: § 14-411.1;
>Maryland Physician Profiles 

>MD database [2011]

MA

2000 law: Chapter 141 of the Acts of 2000 and 1997 Exec. Order Number 405

2000 law: Chapter 141 of the Acts of 2000
 

1996 law: Mass. Gen. Laws Chapter 112 § 5
Massachusetts Doc Profiles [2011]

MI

 

2000 law: Mich. Comp. Laws § 3580

MI - without legislation
Michigan Medical | Michigan Osteopathic [2011]

MS MS physician search: State Medical Board web site [2011] 

MN

1998 law: Medicaid only: Minn. Stat. § 256B.69 Subd. 20 /

1974 law: Minn. Stat. § 62D.08 *

MN - without legislation
Minnesota Physician Profiles [2011]

MT . 2003 law: SB 100 amends Sec. 50-4-312, MCA MT Doctor profiles: State web site [2011]

MO

 

 

1998 law: Mo. Rev. Stat. § 192-068

MO doctor profiles State web site [2011]

NV

1999 law: Nev. Rev. Stat 223.500 ~ 223.850
 

 

NV doctor profiles |
NV State Medical Bd
 State web site [2011]

NJ

2000 law: N.J. Rev. Stat. C.26:2S-19 (A1088)
New Jersey has an Office of the Insurance Claims Ombudsman that serves all types of insurance.  Online description is at: http://www.state.nj.us/dobi/ombuds.htm [2011]

1997 regulation: Admin. Code tit 8, § 38-7.3 **

NJ doctor profiles: State AG web site [2011]

NM

 

 

1994 law: Stat. Ann. Ch. 24, Art. 14A

NM doctor profiles: Medical Board web site [2011]

NY

 

 

1994 law: N.Y. Pub. Health Law § 4410;
2000 law: N.Y. Pub. Health Law § 2995-C

2000 law: N.Y. Pub. Health Law § 2995-A
NY physician profiles: State Dept. of Health web site [2011]

NC

2001 law: S 199; see § 143-730

 

NC - without legislation
 

NC - without legislation
North Carolina Profiles [2011]

ND ND physician profiles: Medical Board web site [2011] 

OH

 

 

 

 

OH - without legislation
Ohio Profiles [2011]

OK

 

 

OK - without legislation

OK - without legislation
Oklahoma Medical Profiles [2011]

OR

 

 

1999 law: Or. Rev. Stat. § 743.801-743.811

OR - without legislation
Oregon Profiles: State Medical Board site [2011] 

PA

 

PA- Agency initiative

PA physician profiles: State agency web site [2011]

RI

1999  law- RI Gen. Laws ch.9.1, sec. 42-9.1 (H6065) Office of the Health Care Advocate

1999 law: R.I. Gen. Laws § 23-17.13

1997 law: RI Gen. Laws § 5-37-9.2 ;
RI physician profiles: State Dept. of Health web site [2011]

TN

 

 

1998 law: Tenn. Code Ann. § 63-51-102

1997, 2000 law: S 2534 >
TN physician profiles: State Dept of Health web site [2011]

TX

1999 law: Tex Ins. Code art. 3.70-3D

1995 law: Tex. Health and Safety Code Ann. §108

1999 law: (H 110)
Texas Profiles: Medical Board web site [2011]

UT

1999 law: § 31A-2-216 (S.56) /

1997 law: Utah Code Ann. § 26-33a-106.5

UT - without legislation
UT Licensee Lookup [2011]

VT

1998 law:
8 VSA § 4089j (H.163)  /

1998 law:
8 VSA §4089b(f)1

VT - without legislation
Vermont Profiles: Medical Board web site [2011] 

VA

1999 law: Chapter 649 /(H.871);
2000 law - (H.726)
Virginia has an online Office of the Managed Care Ombudsman: [2011]
 

1999 law: Va. Code § 54.1-2910.1

1998 law: Va. Code § 54.1-2910.1
1999 law: Chapter 573,
2000 law: Chapter 199
Virginia Profile: Medical Board web site [2011] 

WA

 

WA - without legislation

WA - without legislation
WA health professions profiles: State Dept. of Health [2011]

WV     WV - without legislation
WV Medical Doctor/Podiatrist/Physician Assistant Search: Medical Board web site [2011]

WI

 

WI - without legislation

WI professional license lookup: State agency web site [2011]

WY  .  . WY - without legislation
WY physician directory: Medical Board web site [2011]

* 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)

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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