sumers regarding quality. Without information regarding quality it is difficult for consumers to determine the value of their benefits. Several participants observed, however, that quality may be assessed differently by consumers than by clinicians and purchasers and that more work needs to be done to develop indicators that are particularly relevant and useful to individual elderly consumers.

Information regarding disenrollment rates, appeals and reversal rates, board certification, the training and experience of a plan's doctors, and a detailed participating provider list are also important. Provider lists can be misleading, however. Often, lists include physicians whose panel of patients may be closed or who can accommodate only a few new patients. Some providers are dropped from plans after open enrollment periods end. Some plans may list certain centers as participating providers, but they may only cover such services as open heart surgery at one of these centers and nothing else. This is referred to as the marquee effect.

Beneficiaries and advocates for the elderly express concern that physicians in managed care plans may be in a conflict-of-interest situation in which they are wearing two hats: patient adviser and manager of care and costs. Given the increasing numbers of physicians taking on this dual role and the fact that many Medicare beneficiaries rely on their physicians for advice and protection, Medicare beneficiaries may need to know of noncriticism clauses or "gag rules" between plans and providers. So-called gag rules prevent physicians from criticizing or questioning a plan's rulings. There is concern that physicians may not advise their patients about procedures if those procedures or treatments are not covered by the plan.30


U.S. Healthcare as well as a number of other health plans recently have dropped provisions in their physician contracts that relate to limitations to speak freely with patients. At least six states have enacted legislation preventing health plans from utilizing "gag rules," or anticriticism provisions, which prevent a physician from disclosing financial incentives that may affect patient care. In addition, a bill has been introduced in Congress, H.R. 2976, the "Patient Right to Know Act" that bars restrictions on physician-patient communication in HMO contracts. As of the third week of July, 1996, the bill had nearly 100 cosponsors.

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