MANAGED CARE INITIATIVE WOULD BE RADICAL CHANGE

SAN FRANCISCO-Consumer advocate Harvey Rosenfield and the California Nurses Assn. are preparing a petition to put a proposition on the November ballot that could dramatically affect the state managed care market.

Among other things, the proposition would restrict health care organizations' denial of treatment recommended by the people treating the patient. Treatment could not be denied unless the patient first had a physical exam by someone with qualifications equal to those of the person recommending treatment.

This would prevent "some consultant sitting in Seattle with a cookbook" from denying recommended treatment, said a spokesman for the San Francisco-based nurses' group.

The proposition also would: establish criteria for the denial of care; establish guidelines on what doctors should tell patients about their care; ban financial incentives to limit or deny care; and prevent HMOs and hospitals from retaliating against physicians and nurses who speak out on behalf of patients.

The proposition also would impose fees on mergers and acquisitions, the conversion of non-profit facilities to for-profit facilities and the "excess" stock holdings of health care executives. Proceeds from these fees would go toward enforcing the proposition and public health services.

The drive to gather the required 700,000 signatures is expected to begin in mid-February.

OSHA FAULTS CRITICISM OF ERGONOMICS EFFORTS

WASHINGTON-The Occupational Safety and Health Administration is blasting a report that accuses it of distorting medical research to justify its proposed ergonomic standards.

The Washington-based, business-backed National Coalition on Ergonomics released a study last week saying OSHA did not weigh evidence fairly before proposing the standards. "There are inconsistencies between OSHA's claims regarding study findings and what the cited research actually shows. In addition, OSHA's findings did not fully consider non-occupational factors," said Dr. Richard Blume, an occupational medicine specialist with Sandler Occupational Medicine Associates Inc. in Melville, N.Y.

Assistant Secretary of Labor Joseph A. Dear, who heads OSHA, criticized the National Assn. of Manufacturers-which backs the coalition-for the report. "If NAM wants to debate the science behind ergonomics, then the appropriate place is the regulatory process, in which all interested parties-not just the well-funded special interests-can participate fully and openly," he said.

Debate over the proposed standard, however, is moot because Congress used an appropriations bill specifically to forbid OSHA from issuing such a standard for now. Although an ergonomics standard had been cited as one of the chief workplace safety initiatives of the Clinton administration, it never got beyond the draft stage before Congress put the matter on hold.

COMP RATES FALL 4.7% AFTER WYOMING REFORMS

LANSING, Mich.-A new Michigan law creates the specific crime of insurance fraud and sets penalties of up to four years in prison and $50,000 in fines.

The law, signed by Gov. John Engler, also gives broad immunity from libel or slander suits to those who report suspected fraudulent activity, such as claims adjusters' reporting suspected improprieties to state authorities.

"Once you put in an immunity level.*.*.you do give claims adjusters a higher level of confidence to report fraud," said Rey Becker, associate vp and general manager of the Schaumburg, Ill.-based Alliance of American Insurers. "It's like whistle-blowing insurance."

The insurer-backed law covers property/casualty and workers compensation coverages as well as health insurance, Mr. Becker said.

Under the new law, restitution must be made to defrauded companies, and licensed professionals who are convicted of insurance fraud, such as lawyers or doctors, must be reported to state licensing boards.

BILL WOULD MANDATE EMERGENCY CARE COVER

CHEYENNE, Wyo.-Workers compensation premiums will fall 4.7% on average for Wyoming employers following reforms in 1995 and previous years.

"We essentially took an old-fashioned workers comp system in Wyoming" and modernized it, said Frank Galeotos, director of the Department of Employment, which houses the Division of Workers' Safety and Compensation.

Some legislative changes came in 1990 when the exclusive state fund had unfunded liabilities of $365 million and zero in reserves, he said. But some of the most significant reforms were adopted in 1994 and implemented in 1995.

Safety was encouraged by changing the calculation of employer experience modifications so that claims became a larger liability for employers. A program also was introduced to reward safety. And, safety seminars, managed care and bill review were introduced.

Through 1995 there was a 10% reduction in covered reportable accidents, Mr. Galeotos said. The system now has cash reserves of $110 million and the unfunded liability has been reduced to $280 million.

COMP INSURERS SEEKING RHODE ISLAND RATE CUTS HARRISBURG, Pa.-Health insurers would have to pay for certain emergency room services, whether or not patients requested permission before seeking treatment, under two Pennsylvania Senate bills.

S.B. 1356 and S.B. 1357, introduced Jan. 11 by state Sens. Roy Afflerbach, D-Lehigh County, and James Gerlach, R-Chester County, would require insurers to pay for all emergency room services provided to get a patient stabilized. The companion bills also would require health insurers to reimburse a plan member for emergency services related to any symptom or ailment a reasonable person believes would jeopardize that patient's health or result in serious impairment to bodily functions or serious dysfunction of any body organ or part.

"A plan may deny payment for emergency services only if the plan determines that the services were never performed," S.B. 1357 states. The bill also would permit health plans to deny reimbursement to a provider when the plan enrollee reasonably should have known that an emergency did not exist.

The bills come in response to cases in which insurers have denied payment for what they said was unneeded care in emergency rooms.

PROVIDENCE, R.I.-Workers compensation reforms in Rhode Island have improved claims experience in the state enough to warrant an average 6.7% premium decrease in the voluntary market, says the National Council on Compensation Insurance.

An analysis of the latest data "shows a significant decrease in overall claim frequency and severity in the state in recent years," said William D. Hager, president of NCCI in Boca Raton, Fla.

Effective April 1, 1996, workers comp rates in Rhode Island should decrease 8.9% for manufacturing, 5.9% for goods and services, 11.1% for office and clerical and miscellaneous groups. Workers comp rates for the contracting group should increase by 2.6%, the NCCI says.

The improved claims experience is largely due to reforms enacted in 1990 and 1992, said Ken Christiansen, NCCI's director of government consumer and industry affairs for Rhode Island. Among the changes: limiting permanent total compensation to 75% of the employee's aftertax pay and requiring providers to send insurers itemized billing notices every six weeks.

Other factors in reduced claims are employers' emphasis on workplace safety, growing efforts to combat fraud, and return-to-work and managed care initiatives, he said.

Jeff Post has been named executive vp and chief financial officer of Fireman's Fund Insurance Co. in Novato, Calif., succeeding John Meyer, who died last month....Zurich Insurance Co. is buying $62 million in Zurich Reinsurance Centre Holdings Inc. stock from Fund American Enterprises Holding Inc. After the transaction, Zurich will own 65% of ZRC....A discount that saves Texas businesses about $1 million in annual workers comp insurance costs will remain in force, Insurance Commissioner Elton Bomer has ruled. He refused a request by the Texas Workers' Compensation Insurance Fund to drop the discount to employers in the START program, which provides coverage to those who can't find it elsewhere. Employers with premiums of at least $5,030 are eligible for discounts ranging from 0.1% to 11%.....North Carolina Insurance Commissioner James Long will seek a fourth term. Mr. Long, a Democrat, was first elected in 1984....Armonk, N.Y.-based MBIA Inc., holding company for MBIA Insurance Corp., has filed a registration statement with the Securities and Exchange Commission seeking permission for Aetna Casualty & Surety Co. to sell 2.86 million shares, which would reduce its stake in the financial guarantee insurer to 2.24% from 9.12%, excluding a possible overallotment. MBIA also plans to sell 670,000 new shares as part of the offering. MBIA shares closed at $71.63 on Jan. 25....Houston businessman Martin H. Young Jr. is the new chairman of the Texas Workers Compensation Insurance Fund. Mr. Young, appointed by Gov. George W. Bush, succeeds Larry Durrett, who remains on the fund's board....Jay S. Ralph, president of Centre Reinsurance (Bermuda) Ltd., has been named chief underwriter of Centre Reinsurance Holdings Ltd.'s finite risk operation in Zurich, Switzerland. Michael D. Hamer, president of Centre Re's London and Dublin, Ireland, offices, will become CEO of Centre Reinsurance (Bermuda) Ltd., and Daniel V. Malloy, a senior vp in Bermuda, will become president. Terence G. Wheatley will become president of the London and Dublin offices.