Federal Managed Care Legislation--Patients' Bill of Rights

Three different versions of the managed health care legislation, commonly referred to as the "Patients’ Bill of Rights," are under consideration by Congress. Those bills are

• the House Republican leadership bill, H.R.4250 (sponsored by Rep. Newt Gingrich), which passed the House on July 24 and is now pending in the Senate;
• the Democratic leadership bills, S.1890/H.R3605 (sponsored by Sens. Tom Daschle and Edward Kennedy in the Senate and by Reps. Dick Gephardt and John Dingell in the House); and
• the Senate Republican leadership bill, S.2330 (sponsored by Sen. Trent Lott).

Of the three bills, only the Democratic bills, S.1890/H.R.3605, provide the kind of protections necessary for all patients, and particularly for women. Women-specific criteria required of health care plans in S.1890 include the following:

• Allow women to choose a health care provider specifically trained to meet women’s particular health care needs (such as ob-gyns and geriatricians) as their primary care provider.
• Allow women direct access to ob-gyn services, without referral, regardless of whom they choose as their primary care provider.
• Assure continuity of care (including pregnant women). Patients undergoing treatment can continue to see the same health care provider if their provider leaves a plan or their employer changes plans.
• Include in a plan’s network "essential community providers,"such as family-planning clinics, that traditionally serve women, particularly if the plan serves low-income women.
• Plans may not "arbitrarily interfere with or alter the decision of the treating physician regarding the manner or setting in which particular services are delivered if the services are medically necessary or appropriate for treatment or diagnosis." In other words, treatment decisions are made by a patient’s doctor, not an insurance company.
• Allow doctors to prescribe prescription drugs that are not on the HMO’s predetermined list when needed.
• Plans must adopt mechanisms for confidentiality and ensure individuals’ timely access to their medical records.
• Patients who seek emergency care from a nonparticipating provider may not be required to pay more out of pocket than if such services had been provided by a participating health care provider.
• A plan that refers a patient to a nonparticipating specialist must provide those services at no additional cost to the patient beyond what the patient would have paid for services provided by a participating specialist.
• Plans must have a sufficient number of health care professionals specializing in obstetrics and gynecology.
• Plans must have a sufficient number, distribution, and variety of health care providers to ensure that all covered health care services be available and accessible in a timely manner to all enrollees.
• Plans must provide (without preauthorization) access to emergency services if a reasonable person would consider the situation an emergency and if the plan provides coverage for emergency services.
• Allow patients to see an outside specialist at no additional cost whenever the specialists in their plan cannot meet their needs.
• Managed care plans are held accountable when their decisions to withhold or limit care injure patients. Patients may appeal denials or limitations of care to an external, independent entity whenever their life or health is jeopardized and are guaranteed a fast response. Also, plans are held accountable through an internal quality assurance program that measures performance on health care issues that affect women, and patients have the legal right to hold health plans accountable by pursuing claims for damages for personal injury or wrongful death under state law.
• Plans must collect data on quality indicators and health outcomes on a gender-specific basis.
• Plans must not financially reward health care professionals for limiting a patient’s care.

The Democratic leadership bill is by far the most comprehensive patient protection legislation before both houses of Congress. The two Republican bills either do not include the above provisions or do so only under certain conditions. Both the House and Senate Republican bills (H.R.4250/S.2330) are a sham because they

• let managed care bureaucrats continue to play doctor, making medical decisions best left to patients and their health care professionals;
• do not ensure that patients will have access to specialists when they need them;
• fail to hold HMOs and other managed care plans accountable when their decisions injure or kill people; and
• do not prevent nurses, doctors, and other health care professionals from being fired or otherwise penalized if they advocate on behalf of their patients or report quality problems to appropriate authorities.

The Illinois congressional delegation is divided along party lines on this issue. Sens. Carol Moseley-Braun and Richard Durbin are cosponsors of S.1890. On the House side, the Republicans voted for the Gingrich bill, H.R.4250, and the Democrats voted against it. The Senate adjourned until after Labor Day before a vote was taken on either Senate bill. The Republican Senate bill, S.2330, is scheduled to be voted on in September.

The National Partnership for Women and Families (a Washington, D.C., advocacy organization) is drafting a sign-on letter for local organizations to show their support for S.1890. For more information contact Wendy Pollack at 312.263.3830 ext. 238.