The American Heart Association (AHA) supports the principle that all residents of the United States should have prompt access to and coverage for appropriate quality medical care, particularly for cardiovascular diseases and stroke. The AHA also advocates the development of guidelines for appropriate patient care and supports research into methods to measure quality, outcomes, and cost-effectiveness.
With this in mind, the AHA has gone before federal policy makers to express its concern regarding certain practices used in some managed care settings. A recent survey and report sponsored by the Patient Access to Specialty Care Coalition, including the AHA, has indicated a high level of patient concern over some of these practices of managed care providers. The survey found that 95.1% of respondents felt they should have access to more information about whether an HMO offers financial incentives to physicians to restrict care for cost-containment purposes. Nearly 90% of respondents indicated they considered cost a less important deciding factor in selecting a healthcare plan than access to specialists and treatments of their choice. More than 90% surveyed would not trust a doctor if they knew the doctor was forced, through “gag” clauses and incentives, to limit care. Over half the survey respondents indicated they did not have enough information about managed care practices.
House Representative Greg Ganske (R-IA) was the primary sponsor of the Patient Right to Know Act of 1996. The bill would have prevented all health plans from imposing “gag” clauses in physician contracts that could restrict or interfere with medical judgment. “These gags eat like a cancer at the trust between a health care provider and patient, trust that is at the heart of good medical care,” Representative Ganske said in congressional testimony. “My bill is a balanced approach that addresses a real problem in the health care market.”
In a recent letter to the House of Representatives, AHA President Jan Breslow stated, “In our view, every patient deserves to know explicitly in advance of diagnosis and treatment, that his or her doctor's medical decisions are potentially influenced by this incentive/disincentive style. Patients have a right to know if their particular HMO may restrict their access to some of medicine's most highly-trained doctors, most powerful diagnostic technologies, and most sophisticated treatments.”
The Patient Access to Specialty Care Coalition comprises more than 120 national organizations representing consumers and providers of medical services. The coalition is united in its concern that patients receive access to the specialty care of their choice and have the right to know about all available options. The coalition does not oppose managed care and believes that managed care has a proper place in controlling healthcare costs. However, the coalition is opposed to certain practices that sacrifice the well-being of the patient to control costs.
According to the poll, Americans overwhelmingly want freedom of choice in doctors: 89.4% indicated a willingness to pay more for a traditional health plan or a managed care plan that allowed them to see any doctor or specialist they choose.
In addition, according to a report released by the Pennsylvania Health Care Cost Containment Council in June 1996, patients insured by HMOs and other forms of managed care in the Philadelphia region have “significantly higher” than expected death rates in a study of 36 000 people hospitalized in Pennsylvania with heart attacks in 1993. Dr Alfred A. Bove, chief of cardiology at Temple University Hospital, suggests that the way in which HMOs discourage patients from using emergency rooms may account for higher than expected death rates.
Also of interest is the recent release by the National Committee for Quality Assurance (NCQA) of its Health Plan Employer Data and Information Set (HEDIS 3.0), which measures how well health plans do at helping sick people get better, how effectively plans address the nation's most pressing health problems (such as heart disease), and how consumers view the care they receive. According to NCQA, the report addresses performance measurement for managed care plans, including the control of high blood pressure, preventing stroke in people with atrial fibrillation, and aspirin treatment after a heart attack. It is currently in use by more than 330 health plans nationwide, primarily for their own quality-improvement efforts. The report also addresses availability of primary care providers, access to preventive health services, and children's access to primary care providers.
The American Heart Association and its coalition partners will continue to seek no-nonsense steps that will empower the consumer and allow the marketplace to ensure quality managed health care.
- Copyright © 1997 by American Heart Association