H. 3912 trying to find the right balance

I’d like to clarify some mis-information regarding H. 3912, legislation amending the medical practice act. Many constituents have contacted me asking me not to take away their healthcare rights. This legislation preserves their rights, and helps keep our ever rising healthcare costs in check. Unfortunately, we have fraud and abuse in our system, and we must allow some forms of checks while maintaining quality of care. There is a delicate balance between the two, and hopefully, this legislation is balanced.

I chose to over ride Governor Sanford’s veto on Wednesday 06.25 for several reasons.

In 2006, the legislature passed a revision to the medical practice act that inadvertently created an ambiguity on the issue of whether medical directors who perform utilization review and managed care services for insurers are “practicing medicine.”

The practice act was over fifty pages long and intended to deal with medical licensure and disciplinary issues.  However, what caused the confusion was one line in the definition section that mentioned “medical necessity.”  There was never any discussion of insurance issues either in committee or on the floor of either chamber.

Also, the Department of Insurance issued a bulletin after the practice act was passed in 2006, asking for clarification of the issue and notifying insurers that the Department’s position was that the practice act was not intended to apply to managed care activities by insurers that are subject to the Department’s regulations.

We worked on this legislation with representatives from the The South Carolina Medical Association and the South Carolina Alliance of Health Plans this session and developed a compromise on this issue.  The compromise contained in the bill makes it clear that applying health plan contract exclusions set by employers is not the practice of medicine.  It also states that approving health care claims is not the practice of medicine, and requires that claim denials for services that are allowed under the plan of benefits must be issued by a licensed physician who must adhere to national protocols and medical standards in making those decisions.

It is also very important to point out that this compromise added an additional level of patient – consumer protection:  the bill allows for the Administrative Law Court to review any disputes regarding whether the national standards and protocols for care called for in the bill have been met.

This compromise adds that additional layer of protection for consumers, without dismantling managed care – a serious undertaking that, I believe, will have a dramatic impact on rising healthcare costs.  It carefully addresses the balance needed between protecting consumers on the one hand, while avoiding creating a chilling effect on medical directors and insurers in SC.

I would argue that this is compromiselanguage, neither perfect for the insurance industry nor for the medical association.  Most importantly, I feel strongly that this is a step in the right direction for the patient-consumer and towards managing healthcare costs – something, even now, we can ALL agree we must do.

As a pharmacist and often times am caught in the middle of the prior authorization process. Even though it is burdensome at times, I do believe the process is necessary as it adds some checks and balances in our ever increasing healthcare costs. Hopefully this legislation provides a balance in the system that will allow for high quality of care standards, yet decelerate the escalating costs of health care and health care insurance premiums.

As you may know by now, the Governor’s veto of this bill was overridden in the SC House by a vote of 96 to 13 and in the State Senate by a vote of 34 to 5.  I hope this answers any questions you might have about why, after much deliberation with my colleagues in the legislature and thought, I decided to vote to override Governor Sanford’s veto on this bill.