|
|
|
Managing Managed Care
|
Business New Haven
3/5/2001
By: BNH
|
Gerald Martens was named the state's managed-care ombudsman by Gov. John G. Rowland last August. The ombudsman's office is an independent agency established by the legislature in 1999. Martens is a former benefits manager at Carpenter Technology, a Bridgeport steel company, for seven years and for the most recent 13 years was the company's manager of health-care planning. As ombudsman, Martens will assist consumers in choosing their health plan and in understanding and exercising their rights under those plans.
How large is your staff?
We have a secretary and a deputy ombudsman, and we're hoping to hire a fourth person soon.
When it created this position, what did the legislature seem to have in mind about what a managed-care ombudsman would do? And how do you see it?
Generally speaking, the office was created to help the 1.1 million members of HMOs in Connecticut with problems related to managed care.
They call you up because they got denied a claim or something?
That would be one issue. Another one would be if they had problems with plan selection or if they had problems related to finding out what they should do in a potentially high cost case. We do a lot of different things in terms of educating the public about managed-care issues.
It sounds as though an office of four people - or even 40 - can't possibly be sufficient judging by the number of managed-care horror stories. Can you get the job done at your staffing level?
It has taken a while to roll out the office. The plan for the office was first to investigate all the various state agencies that could be of help in these areas. We are working very closely with the insurance commissioner and the attorney general's office to find out what each department's strengths are. We will be taking calls from the public when we roll out the office in April. Then [it's a matter of] triaging those calls and referring them either here, the insurance department or to the attorney general's office, depending on the situation.
The insurance department has oversight on matters over fully insured programs, and its purview is basically to mediate in areas where there are contractual issues or statutory or regulatory issues and insure that the public is getting what they pay for. However, half of the people in managed care in Connecticut are in self-insured plans.
When will you be up and running as far as the pubic is concerned?
In April we are hoping to open our telephone lies and our Web site. At that time we'll be able to handle large volumes of calls and do the appropriate referral and to help people access our services on the Internet.
What authority do you actually have? Also, is your mandate to assist companies as well as individuals?
Basically we've only dealt with individuals, but we'll take calls from anybody who's having issues relating to managed care. We have the authority to obtain all consumer records relating to a complaint from the HMO, to hold hearings on different problems as they arise. We will take the result of those hearings and we can work with the insurance department, with the legislature or with the attorney general in terms of appropriate action that his office may deem necessary. There are adequate patient protections in place.
Are you talking about the kind of individual hearings that we would have in a workers comp or unemployment claim?
It would be a public hearing.
Are there other states that have managed-care ombudsmen?
We're fairly unique in that we are an independent agency. Other states have ombudsmen programs; sometimes they are funded through the state but managed by advocacy groups within the state or sometimes they are part of an agency like the department of insurance in Massachusetts and Virginia. The most successful programs have been independent programs.
How did the HMO industry respond to this legislative action?
My sense is they were not in favor of establishing this office. The [HMOs] felt they were doing an adequate job of handling their consumers. They were probably the only people with that opinion at the time.
What do you expect to be able to accomplish in the mid- to long-term?
The enabling legislation mandates a broad base of duties. Part of it is to deal with individuals, part is to work with the legislature in bringing to them issues relating to consumer problems and helping them fashion legislation and regulations that will help consumers. Part of it is general public education, which we are going to start in April as well. It really is a very broad-based charge that we have here. As we go along we're discovering ways to help consumers and to incorporate them into the program.
Is there a role for providers like doctors in the legislation?
Not directly, but we do have two physicians on our board of advisors. Additionally there are two advisors from the advocacy community, a trial lawyer and a [lobbyist lawyer] from the HMO association. The advisory board was created by the legislation to help craft the message, but it is not a governing board.
What did we miss?
One of the questions is, What is the state of managed care in Connecticut right now? The answer is that there are a number of issues facing managed care. There is the rapid consolidation of health plans through mergers and acquisitions, which has created problems for consumers. And there is a general confusion on the part of the public about what managed care is all about. A big part of our budget is dedicated to education. The budget includes the four positions and a discretionary budget of $300,000 for next year.
|
Go FirstGo PreviousGo
NextGo LastGo
to Index
|
|
