In re 1987-88 Medical Doctor Provider Class Plan

514 N.W.2d 471, 203 Mich. App. 707
CourtMichigan Court of Appeals
DecidedFebruary 22, 1994
DocketDocket Nos. 144058, 146046
StatusPublished
Cited by6 cases

This text of 514 N.W.2d 471 (In re 1987-88 Medical Doctor Provider Class Plan) is published on Counsel Stack Legal Research, covering Michigan Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
In re 1987-88 Medical Doctor Provider Class Plan, 514 N.W.2d 471, 203 Mich. App. 707 (Mich. Ct. App. 1994).

Opinions

Holbrook, Jr., P.J.

These appeals are from the August 5, 1991, decision and several subsequent ancillary orders of Independent Hearing Officer (iho) Robert Borsos issued under part 5 of the Nonprofit Health Care Corporation Reform Act, 1980 PA 350, MCL 550.1101 et seq.; MSA 24.660(101) et seq., effective April 3, 1981. The iho reversed the August 16, 1990, determination of the Insurance Commissioner (ic), MCL 550.1510; MSA 24.660(510), and ordered appellant Blue Cross and Blue Shield of Michigan (bcbsm) to transmit to the iho a remedial plan for determination by the iho whether the remedial plan should be retained. The plan involved is the 1987-88 medical doctor provider class plan, which affects over ten thousand doctors and several million bcbsm subscribers.

This case represents the first time an iho has been used for an appeal under part 5 of the act. In Blue Cross & Blue Shield of Michigan v Governor, 422 Mich 1; 367 NW2d 1 (1985), the Court rejected [711]*711bcbsm’s argument that ihos unconstitutionally were delegated authority and were wholly unaccountable. Id. at 55-59. The Court declined to rule on bcbsm’s claim that the statutory "goals” of reasonable access, quality, and cost of medical care were unconstitutionally vague and illusory. Id. at 92-93. This appeal presents numerous issues concerning the nature of the "appeal” before an iho and the extent of an iho’s authority.

THE NONPROFIT HEALTH CARE CORPORATION REFORM ACT

The historical background of the act is described in BCBSM v Governor. Id. at 13-18. The act was designed to broaden the ic’s power to regulate bcbsm’s rates. Id. at 17-18, 49. The "primary objective” of the act is "to check rising health care costs.” Id. at 18. The act is "aimed at curbing the rise in health care costs by a unique statutory scheme which combines both free-market and government regulatory methods of control.” Id.

The act itself states its purpose and intent is "to promote an appropriate distribution of health care services for all residents of this state” and "to assure . . . reasonable access to, and reasonable cost and quality of, health care services,” among other things. MCL 550.1102(1); MSA 24.660(102)(1). The Legislature vested the ic with the primary authority to regulate bcbsm and to see that the act’s requirements were satisfied. MCL 550.1102(2), 550.1601; MSA 24.660(102)(2), 24.660(601).

PROVIDER CLASS PLANS

The act requires bcbsm to file "provider class plans” with the ic. MCL 550.1506(1); MSA 24.600(506)(1). A provider class is a class of care [712]*712providers, such as medical doctors. Section 107(6), MCL 550.1107(6); MSA 24.660(107)(6). A "provider class plan” is a document containing the reimbursement arrangement pertaining to the class of providers, "objectives” for the provider class, and the contract provisions bcbsm has with the providers. Section 107(7).

The act directs bcbsm to enter into contracts with providers that assure subscribers reasonable access, reasonable costs, and reasonable quality of health care in accordance with described goals. MCL 550.1504(1); MSA 24.660(504X1) states:

A health care corporation shall, with respect to providers, contract with or enter into a reimbursement arrangement to assure subscribers reasonable access to, and reasonable cost and quality of, health care services, in accordance with the following goals:
(a) There will be an appropriate number of providers throughout this state to assure the availability of certificate-covered health care services to each subscriber.
(b) Providers will meet and abide by reasonable standards of health care quality.
(c) Providers will be subject to reimbursement arrangements that will assure a rate of change in the total corporation payment per member to each provider class that is not higher than the compound rate of inflation and real economic growth.

The act’s preamble and § 102(3) express the Legislature’s desire for an expeditious and effective procedure for administrative appeals relative to provider class plans. Regarding administrative review of provider class plans, the act is to be construed "to minimize uncertainty and delays.”

REVIEW OP PROVIDER CLASS PLANS

When bcbsm initially transmits a plan to the ic, [713]*713the ic is to examine the plan and determine "only” if the plan contains a reimbursement arrangement and "objectives [defined in § 106(5), MCL 550.1106(5); MSA 24.660(106X5)] for each goal” provided in § 504. Section 506(2). If the ic does not disapprove or does not act within fifteen days, the plan automatically goes into effect and is "retained.” Section 506(4).

A provider class plan retained under § 506(4) may be more thoroughly reviewed after two years. Section 509(l)(b), MCL 550.1509(l)(b); MSA 24.660(509)(l)(b). The ic must determine whether the health care corporation "has substantially achieved the goals of a corporation as provided in section 504 and achieved the objectives contained in the provider class plan.” Section 509(1). The ic has six months to make a determination. Section 509(2). The ic is required to consider the "overall balance” of the statutory goals as well as information gathered "for the record” that pertains to health and economic trends, changes in legislation, and comments from interested persons. Section 509(4). Such comments are encouraged, even during the review process, by § 505(2), MCL 550.1505(2); MSA 24.660(505)(2). A detailed statement in support of the ic’s determination is required. Section 509(5). The determination process by the ic is not a contested case hearing under Chapter 4 of the Administrative Procedures Act, MCL 24.271-24.287; MSA 3.560(171)-3.560(187).

Under MCL 550.1510(l)(a)-(l)(c); MSA 24.660(510)(l)(a)-(l)(c) the ic must make one of three determinations: (1) the plan achieves the corporation’s § 504 goals; (2) the plan fails to substantially achieve one or more of the goals but, based on competent, material, and substantial information, the failure is reasonable, in which case the plan need not be changed; or (3) the plan fails [714]*714to substantially achieve one or more of the statutory goals. If an unreasonable failure is found, the ic must prepare a "concise written statement of specific findings.” Section 510(2). If the plan is found satisfactory under § 510, the review process does not continue. But an appeal to an iho is available. Section 515(1), MCL 550.1515(1); MSA 24.660(515)(1). The instant case is such an appeal.

If the plan is found inadequate by the ic, then the health care corporation must transmit a remedial plan within six months that "substantially achieves the goals, achieves the objectives, and substantially overcomes the deficiencies enumerated in the findings made by the commissioner” under §510(2). Section 511(1), MCL 550.1511(1); MSA 24.660(511)(1). If the health care corporation does not act in six months, the ic is required to prepare a plan. Section 511(2).

Once a health care corporation submits a remedial plan under § 511, the ic has ninety days to determine whether the plan substantially achieves the goals, achieves the objectives, and substantially overcomes the deficiencies previously enumerated by the ic. Section 513(1), MCL 550.1513(1); MSA 24.660(513)(1).

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Cite This Page — Counsel Stack

Bluebook (online)
514 N.W.2d 471, 203 Mich. App. 707, Counsel Stack Legal Research, https://law.counselstack.com/opinion/in-re-1987-88-medical-doctor-provider-class-plan-michctapp-1994.