ByÂ ROBERT PEAR, The New York Times
WASHINGTON â€”Â Health insurance companies are lobbying federal and state officials in an effort to ward off strict regulation of premiums and profits under the new health care law.
The effort is, in some ways, a continuation of the battle over health care that consumed Congress last year.
Insurance lobbyists are trying to shape regulations that will define â€œunreasonableâ€ premium increases and require them to pay rebates to consumers if the companies do not spend enough on patient care.
For their part, consumer groups say they worry that their legislative victories could be undone or undercut by the rules being written by the federal government and the states.
The health care overhaul provides a classic example of how the impact of a law depends on regulations needed to interpret it. The rules deal with relatively technical questions but go to the heart of the law, pushed through Congress byÂ President Obama and Democratic leaders with no Republican support.
More than 40 provisions of the law require or permit agencies to issue rules. Lobbyists are focusing on two whose stated purpose is to ensure that consumers â€œget value for their dollars.â€
One bars insurers from carrying out an â€œunreasonable premium increaseâ€ unless they first submit justifications to federal and state officials. Congress did not say what is unreasonable, leaving that to rule writers.
Another provision, effective Jan. 1, requires that a minimum percentage of premium dollars be spent on true medical costs related to patient care â€” not retained by insurers as profit or used to cover administrative expenses. Insurers must refund money to consumers if they do not meet the standards, known as minimum loss ratios.
Michael W. Fedyna, vice president and chief actuary ofÂ Aetna, underlined the importance of this issue, saying no other aspect of the law would be so â€œinfluential in shaping the future of the health care marketplace in the United States.â€
The definition of medical loss ratio will â€œdetermine the willingness of health plans to enter new markets and remain in existing markets,â€ he said.
SenatorÂ John D. Rockefeller IV, Democrat of West Virginia, said the definition would be just as important for consumers and small businesses.
â€œThe health insurance industry has shifted its focus from opposingÂ health care reform to influencing how the new law will be implemented,â€ he said.
The law requires insurers to spend a minimum percentage of premiums on health care services and â€œactivities that improve health care qualityâ€ for patients.
Insurers are eager to classify as many expenses as possible in these categories, so they can meet the new test and avoid paying rebates to policyholders.
Thus, insurers are lobbying for a broad definition of quality improvement activities that would allow them to count spending on health information technology, nurse hot lines and efforts to prevent fraud. They also want to include the cost of reviewing care by doctors andÂ hospitals, to determine if it was appropriate and followed clinical protocols.
Some consumer advocates, like Carmen L. Balber of Consumer Watchdog, favor a strict, narrow definition of quality improvement activities, limited to those that produce measurable benefits to individual patients.
To read more, visit: http://www.nytimes.com/2010/05/16/health/policy/16health.html?src=me
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