May17,2001

The Honorable Casper R. Taylor, Jr.
Speaker of the House
State House
Annapolis MD 21401

Dear Mr. Speaker:

In accordance with Article II, Section 17 of the Maryland Constitution, I have today vetoed House Bill 473 - Health Maintenance Organizations - Patient Access to Choice of Provider.

House Bill 473 authorizes nurse practitioners to serve as primary care providers for health maintenance organizations (HMO) but does not require an HMO to include nurse practitioners on the provider panel as primary care providers. House Bill 473 also provides that the number of nurse practitioners on the provider panel of an HMO may not exceed 50% of the total number of primary care providers on the provider panel. An HMO may not require or attempt to require a member or subscriber to select or be seen by a nurse practitioner. In addition, House Bill 473 also requires an HMO to individually credential each nurse practitioner who serves as a primary care provider for the HMO and requires the State Board of Nursing to create and maintain an individual profile on each nurse practitioner certified by the Board.

It is with regret that I must veto House Bill 473. The nursing profession is a valued part of the health care delivery system. The tremendous contribution made by nurse practitioners in providing quality health care in Maryland cannot be questioned. Rather, I believe that this bill raises significant questions concerning the delivery of health care by HMOs.

The creation of the HMO legislation in the 1970s was premised on members having access to a primary care physician to coordinate their care. Since its adoption, the State has been required to take the position of "watchdog" in order to protect members from potential abuses of HMOs in trying to limit this access. For example, Maryland law requires HMOs to have a system for providing members 24-hour access to a physician in cases where there is an immediate need for medical services and for promoting timely access to and continuity of health care services for members. Laws also exist to ensure that HMOs provide for regular hours during which members may receive services and that members have access to services within their geographic location. In 1999, due to ongoing consumer concerns about the quality of care provided by HMOs, the General Assembly passed and I signed legislation to create the HMO Quality Assurance Unit within the Department of Health and Mental Hygiene to further ensure that HMOs were providing care in accordance with the law. The Honorable Casper R. Taylor, Jr. May 17, 2001 Page Two Consequently, given this history, I am concerned that HMOs will undermine the intent of this law and restrict access to physicians. While I understand that House Bill 473 contains provisions to address this concern, I do not believe that these provisions go far enough. Under these provisions, the number of nurse practitioners that an HMO may include on a primary care provider panel may not exceed 50% of the total number of providers on the panel. However, this provision does not address whether an HMO will terminate a physician from a panel in order to replace that physician with a nurse practitioner. This situation could be very troubling to members who have established a relationship with that physician. Equally troubling could be the situation where the limited number of physicians requires a member to either choose a nurse practitioner as his/her primary care provider or switch HMOs.

Moreover, it is unclear whether HMOs could use incentives to encourage members to choose nurse practitioners as their primary care providers. This bill, designed to improve consumer choice, could have the undesired effect of using economic measures to unduly influence consumer choice. I believe that this issue needs to be clarified to ensure that the intent of this legislation is not misinterpreted.

While the above concerns prevent me from signing House Bill 473 into law, I agree with the sponsors and proponents that we should do more to ensure that the citizens of Maryland continue to receive quality health care. I urge both sides of this issue to work together to reach consensus on this issue in time for the 2002 Session.

For the above reasons, I have vetoed House Bill 473.

Sincerely,
Parris N. Glendening
Governor