Health Reform on the Line
The next few months will see a shift in focus at the federal level. After months of White House scandal, the business of lawmaking begins again; and nothing promises more controversy than the proposed “patient bill of rights.” An attempt to pass patient protection or patient rights bills last session fell to the majority’s indifference, insurers’ opposition, and the sudden shift in focus from the nation’s business to that of the President.
To say that there is grassroots support for some kind of law that provides protection against the worst of decisions made by HMOs and the host of alphabet-named groups that mimic them minimizes the level of the public’s concern. Every poll taken gives evidence that the public wants some kind of law; likewise, so do most organized medical groups. The question remains, however, as to whether the political will to tackle the issue exists.
In some cases, the decisions made by managed care organizations cost lives. In others, they simply visit on patients the kind of hassle factor that has faced their physicians for years. A woman with pneumonia and laryngitis finds herself on interminable hold as she tries to get an appointment with an ear, nose, and throat specialist while her voice slowly fades away. A mother with a distraught child who has an earache is told the earliest available appointment is next week. The father who took his child to the emergency room late at night now finds that the insurer will not pay because he took his son to last year’s approved emergency room, not this year’s. The hassle factor has come home to roost.
In many instances, the delays do serve to cut costs and eliminate some unnecessary procedures and treatments. However, in some horrible cases, a person dies while the physicians, insurers, and hospitals negotiate over payment.
Two years ago, the Texas Legislature passed a law that gave patients the right to sue their HMOs for malpractice. A recent court case seems to have limited those suits to instances in which patients are harmed, but the case has yet to wend its way fully through the courts. However, this law (and those similar to it in other states) applies only to people whose insurance is regulated by state agencies. In the United States, most privately insured people are members of self-insured plans that fall under a law called ERISA or the Employee Retirement Income Security Act.
With new legislation already introduced into the 106th Congress, hearings are scheduled for March and April. With luck, the final vote on legislation may come as early as May or June. These bills have created some strange bedfellows.
Nancy Dickey, MD, the current AMA president and an associate professor of family medicine at Texas A&M Medical School in College Station, said her group aims to lobby vigorously in favor of strong patient protection legislation. “We will go full speed ahead to get a good law passed,” she said after a recent speech in Houston.
In the same vein, Judith Waxman, legislative director for the patient advocacy group called Families USA, said she anticipates that hearings on different proposed laws will take place in March and April: “I expect something will emerge.” She said she anticipates that the insurance industry, along with some employers, will oppose attempts at legislation. Industry spokesman Don White of the American Association of Health Plans (AAHP), said his group opposes any legislation, even Republican-sponsored bills that substantially water down protections. He said he thinks the legislation will raise the cost of health care.
He said the proposed rules “set a dangerous precedent for interference by the federal government,” adding, “as health care costs increase, the need for a cost-conscious health care delivery system is also increased.”
Advocates for a law to protect patients want:
Access to emergency room care when patients legitimately feel they need it
Access to providers who are not on the HMO’s panel
To allow doctor-specialists to provide primary care to the patients who have severe long-term diseases in their area
To permit patients with serious long-term diseases to see their specialists without getting a referral from a primary care doctor each time, and to allow women to make direct appointments with their obstetricians and gynecologists
Continuity of care encouraged by allowing patients to finish a course of treatment with a physician, even after the doctor is dropped from a health plan
Formularies that allow doctors to prescribe any drug as long as it is the best one to solve the patient’s medical problem
Doctors, not the plan’s personnel, to make decisions about length of stay and other care
To set up an outside complaint review process for patients who disagree with decisions made by their health plans
Anti-gag provisions that allow a doctor to discuss any treatment options that can help a patient, even if the treatments are not covered by the health plan
A prohibition on financial incentives that induce physicians to reduce their costs of care by limiting treatment
Coverage for the costs of routine treatment for patients in clinical trials
Doctors to receive due process; this means that insurance companies would have to tell them why they have been dismissed from a panel of doctors providing care under a plan
Protection for physicians who file appeals or are patient advocates
Depending on the bill, some or all of these rights are guaranteed under proposed legislation in both houses of Congress. In general, legislation sponsored by Democratic representatives and senators is more likely to provide a broader set of rights than that sponsored by Republicans.
The AAHP asserts the claims about poor quality care in managed care organizations, lack of choice in physicians, and restricted access to physician-specialists are not borne out by published studies. In a position paper on the issue, the AAHP asserts: “Financial incentive arrangements between health plans and providers are beneficial to patients. Often, they are linked to quality of care and patient satisfaction, as well as utilization patterns. Increasingly, practitioners value risk sharing arrangements.” The group denies that the industry has ever used “gag clauses” to stop physicians from discussing expensive treatments with their patients.
Ms. Waxman warns that getting the bill passed will depend on influential people making their preferences known. She predicts that insurance companies will spend millions to fight any kind of law coming out of the 106th Congress.
- Copyright © 1999 by American Heart Association