The debate over whether patients should have a “bill of rights” offering basic protections from health plan abuses has finally reached a critical mass on Capitol Hill. In October of 1999, the House of Representatives passed a strong patient protection measure in dramatic fashion. After rejecting eleventh hour efforts by the Republican leadership to pass their weakened version of managed care reform, 68 Republicans crossed party lines to join with the Democrats to pass bipartisan managed care legislation by a vote of 275-251. The measure passed by the House was sponsored by Charlie Norwood (R-GA) and John Dingell (D-MI).
Passage of this legislation was a significant victory for physicians and their patients, as the insurance industry and business interests have waged a multi-million dollar campaign this year to defeat the Norwood/Dingell bill. However, the Senate passed a much weaker patient protection measure in July of 1999. The ultimate result will depend on whether a House/Senate Conference Committee can resolve the considerable differences between the two bills, and whether the President will sign the compromise bill.
In any event, the conference is likely to extend into 2001. Following is a comparison of the House and Senate legislation.
Areas of Similarity
There are several issues in the bills where agreement by both bodies is likely. They include:
- Gag-clauses: Both bills ban the use of “gag clauses,” which prohibit physicians from discussing certain treatment options with their patients due to financial considerations. Patients should never have to question whether their physician may be withholding significant information due to contractual obligations with health plans.
- Point of Service: Both bills allow patients in managed care plans to have the opportunity to choose an out-of-network “point-of-service” option, allowing them to be treated by the provider of their choice if they are willing to assume any added costs associated with this option. The Senate bill has an exemption for small businesses with 50 or fewer employees that is objectionable.
- Access to Specialty Care: The final bill will likely guarantee timely access to any qualified participating specialist, with appropriate clinical expertise, who is available to accept the patient for care. If an appropriate in-network specialist is not available, a patient must have timely access to out-of-network specialists at no additional cost.
- Access to Emergency Room Services: Both bills require the health plan to provide emergency care coverage to patients for symptoms that would reasonably suggest to an average person that their health could be at serious risk, including severe pain. Certain services necessary to treat and stabilize the patient also may be covered in the final bill.
- Internal and External Appeals: The final agreement is likely to provide patients with notice of and the right to fair and timely internal and external appeals. The external appeals process will probably require an independent reviewer with clinical expertise in the area where the review is being conducted.
- Information Disclosure: Both of the bills require that patients be provided with all of the information relating to a health plan’s benefits and procedures, including all appeals processes, limitations and exclusions.
Areas if Difference
There also are several areas in the bills where the two government bodies disagree. They include:
- Financial Incentives: While the House bill prohibits financial relationships between a health plan and a provider that could serve as an inducement to reduce or limit access to medically necessary services, the Senate bill has no such provision.
- ERISA Reform: The Employee Retirement Income Security Act (ERISA) of 1974 preempts state laws that allow individuals to sue for wrongful death or injury resulting from the medical decisions of insurance companies. The House bill strikes the federal preemption responsible for this loophole and allows patients to sue HMOs. The Senate bill contains no ERISA reform.
- Scope: The Senate bill only covers 48 million Americans in self-insured ERISA plans, while the House bill extends patient protections to all 161 million working Americans.
Role of the AANS
The AANS, through its membership in the Patient Access Coalition, continues to be an active participant in this debate. The Coalition has clarified its “principles” to better fit the current legislative activity, and representatives from the AANS continue to meet with Congressional staff and Members of Congress on this issue.
A Call to Action
To end this debate, it is essential that every neurosurgeon contact their Members of Congress and urge them to work with the Conference Committee to develop meaningful patient protection legislation. For your convenience, NEUROSURGERY://ON-CALL® has established a free link providing instant e-mail communication to Members of Congress. Visit N://OC® www.neurosurgery.org today, and tell Congress that you want an end to HMO abuses.