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Health plan restrictions reappear

Firms returning to once-vilified curbs as costs rise

NEW YORK -- Surging costs have prompted healthcare plans to revive unpopular money-saving measures that were scaled back after a backlash against managed care during the late 1990s, a study reported yesterday.

Requirements such as referrals for specialists and preauthorizations for some medical services are quietly reappearing, according to a study published in the policy journal Health Affairs.

''Health plans are revisiting some of the cost measures that were vilified in the backlash against managed care because there is still some optimism that the tools can be effective," said Glen Mays, research director at the Department of Health Policy and Management at the University of Arkansas for Medical Science.

Mays, one of the study's three authors, said five to six years of double-digit increases in healthcare costs have pushed employers and health plans to reconsider old options.

Employees balked at restrictive policies during the late 1990s and employers responded by offering plans with much broader networks and fewer limitations. But the labor market then was tight and employers didn't want to risk losing employees. Mays said the combination of a higher unemployment that keeps workers at their jobs and employees' frustration with rising premiums and copayments may make some restrictions more palatable.

However, the study's authors said the new requirements are not as severe as similar rules during the 1990s, when managed care stridently restricted access to hold down costs. ''Insurers are being more selective on how they use these measures," Mays said.

For example, since 2001, five of the 56 health plans in the survey increased their use of prior authorization requirements for outpatient services. There was no change in requirements for hospital preauthorizations. Mays said that is because unnecessary hospitalizations are rare.

The study found that in 2000-2001, Aetna eliminated prior authorization for about 50 inpatient and outpatient services in northern New Jersey. But the company reinstated the policy in 2002-2003 after use sharply increased. Likewise, Excellus BlueCross BlueShield in Syracuse, N.Y., reinstated prior authorization requirements for specialist referrals after referrals rates rose when the requirement was eliminated.

Other techniques making a comeback include reviewing patient care when a person is in the hospital or undergoing extensive outpatient treatment to ensure all services are necessary. Seven of the 56 plans increased use of such programs since 2001; 15 plans increased their use of retrospective review of treatments and profiling of hospitals and doctors.

But even though plans are being more careful to use restrictions wisely, it doesn't mean employees won't balk. Consultant Ed Kaplan said that one of his clients began requiring preauthorizations on tests that cost more than $500 in July. Patients have already complained. Because employees are now paying more, they feel they should have more access, Kaplan said. ''There'll be more delays and barriers for patients," he said. ''When you tighten access, there are problems."

The study was conducted in 12 locations, including Boston.

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