Maryland's General Assembly is on the verge of enacting a pair of health-care reform bills that have been targets in a multi-year war among doctors, health maintenance organizations, hospitals, insurers and others.
One of the bills would ensure that HMO patients may see doctors outside their network, as long as they are willing to pay for the privilege. The other would, for the first time, require the state to license free-standing surgery facilities, birthing centers and other types of walk-in clinics.
House and Senate versions of the two bills differ in several respects, but legislators say compromises are within reach and that both measures appear headed for passage.
"I think this thing is greased now," House Speaker Casper R. Taylor Jr. said yesterday after the Senate Finance Committee unanimously passed its version of the so-called "patient-access" bill.
The House of Delegates passed a similar measure Friday, but the Finance Committee had been considered a potential stumbling block.
Doctors, who sometimes find themselves excluded from the "managed-care" networks that are popular with cost-conscious employers, have been battling for years to reclaim a share of the health care business.
Bills in both houses would establish rules that HMOs and other networks must follow in considering and responding to the applications of doctors to join their networks.
Some doctors also have argued that patients are fed up with the restrictions of HMOs, which they characterize as more concerned with bottom-line results than quality health care.
They persuaded the House to prohibit HMOs from withholding part of the monthly pay owed to doctors while their performance is reviewed. Doctors say the practice is designed to penalize physicians who refer their patients to costly specialists.
"People are mad at HMOs and they have a right to be," said Joseph A. Schwartz III, lobbyist for the state medical society.
The HMOs counter that such practices are basic to the managed-care approach to medicine, and that withholding pay is the stick that produces the savings the public is demanding.
Senators would like to postpone action on the issue until next year, after summer study. Differences over that and other issues must be resolved by a House-Senate conference committee.
"The ultimate goal is to help the consumer of health care," said Mr. Taylor, an Allegany County Democrat.
"We're trying to do it without over-regulating or stifling the market. But it is anybody's judgment if we have found the right balance between regulation and a free market," he said.
Earlier yesterday, the full Senate voted 46-1 to pass its version of the bill regulating ambulatory care facilities. The House passed its bill last week, 134-3.
Both would require state licensing of birthing, kidney dialysis and ambulatory surgical centers, among other facilities.
The bills also would require any surgical center with more than one operating room to go through the state's existing "certificate of need" process, which is designed to control the number and location of health care facilities.
Pegeen Townsend, lobbyist for the Maryland Hospital Association, said Maryland has "three times as much surgical capacity as the national average."
She said many of the new surgery centers are located in suburban parts of the state, where most residents are insured, rather than in areas where the need for lower-cost alternatives might be greater.
Two cost-sharing provisions that could have prevented passage of the ambulatory care legislation this year instead were sent to summer study.
One involves the question of whether such facilities should have to pay a fee as their share of the system-wide cost of providing medical care to those who cannot afford to pay.
The other is a proposal to spread the cost of graduate medical education -- now borne largely by the state's two teaching hospitals, Johns Hopkins and the University of Maryland -- to other hospitals.