A set of protections for Americans in managed-care
plans was pushed through the Senate on June 30, 2001, sounding a victory
for Democrats after years of political clashes. However, the nation's
largest health insurers have already started to give their patient's
much of the care that a federal law would guarantee. Ironically, no
one mentioned that during the feverish oratory leading up to the Senate
Whenever patients believed they needed to go,
Aetna U.S. HealthCare, Inc., the nation's largest managed-care company,
started paying for emergency room visits four summers ago. Physicians
were told they no longer needed the company's permission to perform
most medical procedures in 1999 by United HealthCare. In many states
dissatisfied patients are now allowed to file grievances with outside
appeals boards by Blue Cross and Blue Shield plans.
In fact, the private marketplace has reacted
much more rapidly than the government when confronted with rampant
consumer resentment of managed care. W. Allen Schaffer, senior vice
president and chief medical offices of Cigna HealthCare, which insures
14 million people said given the changes that major health plans have
already made, a federal law "seems anachronistic - like an idea whose
time has gone."
The government's slow motion on patients’ rights
illustrates how difficult it is for the government to improve people's
medical care, even in limited ways nearly a decade after Congress
spurned former President Bill Clinton's ambitious plan to overhaul
the U.S. health care system.
Congress is arguing over problems with managed
care that the industry has already started to resolve, while the government
has not shifted its attention to a fresh problem according to health
insurance executives, researchers, and leading corporate benefits'
consultants. Once again, medical inflation has started to climb rapidly
after relatively calm for several years. The reason for the increase
has been the relaxed constraints of managed-care plans on medical
care - precisely the way a patients’ bill of rights would require.
Frank Sloan, director of Duke University's Center
for Health Policy Law and Management said, "Congress doing what's
it's doing now is picking up somewhat late in the game."
The insurance industry has fought vigorously against
a patients’ bill of rights, arguing that the government should not
promise people easier access to medical specialists or emergency room
care - benefits that most health plans controlled tightly at the time
when Congress first started to talk of giving patients more clout
against health maintenance organizations.
However, the debate narrowed to one main issue
as the political appeal of these proposals grew and as the care they
would guarantee became more common. The fact that they agreed on the
kinds of care patients should be guaranteed is proudly cited by politicians
of both parties. And the main change health insurers now fear – giving
patients more freedom to sue their plans – the political parties continue
However, far more important to most patients is
their ability to see the kind of physician they want than the right
to sue say consumer advocates and industry analysts. Political pressure
for more regulation has remained intense as a result of a variety
of surveys demonstrating that the recent changes in managed care have
not lessened public antipathy toward managed care.
Not entirely unrelated to government action are
the changes that the managed care industry has adopted. In an effort
to ward off more federal regulation, the industry has been eager to
demonstrate that it can improve itself.
A voluntary code of conduct for its members has
been created by the American Association of Health Plans. For example,
plans should not prohibit physicians from discussing expensive treatment
options with their patients. (The Senate bill has this feature).
An accreditation system for managed-care plans
that agree to meet certain standards is run by the Washington-based
National Committee for Quality Assurance. The legislation Congress
has been debating increasingly match those standards. For example,
the committee included a requirement that plans allow their patients
to bring in outside appeals board complaints two years ago.
A growing number of states have adopted managed
care laws during the past few years that have influenced HMO's rules
even in the absence of a federal law say analysts. Currently patients
are given avenues for appealing health plans' decision and have made
it easier for people to get emergency-room bills paid by about 40
states. Certain patients are allowed to temporarily keep physicians
who have left a health plan or see some kinds of medical specialists
without needing prior approval from their primary physician by more
than 30 states.
State laws - and the specter of federal regulation
have not been the main reason they have changed their rules say managed-care
officials. William Popik, Aetna's chief medical officer said, "The
motivation was, it's what consumers wanted us to do."
During the past several years, large employers
were willing to heed complaints about the frustrations of dealing
with managed care and to purchase the type of coverage that gave employees
more medical freedom said Peter Kongstvedt, a benefits consultant
with Cap Gemni Ernst & Young. As the economy boomed and companies
were eager to offer good benefits to attract scarce workers, this
was particularly true.
Far less significant are some of the major problems
the bills in Congress are trying to fix - obstacles to seeing the
type of physician patients want - in such a climate. To looser "preferred
provider" arrangements that give people discounts for seeing physicians
in a health plan's network but that let them see other doctors for
a higher fee, large numbers of Americans have switched from tightly
Some plans have also gone further than a federal
law would require, allowing people to easily visit types of specialists
not mentioned in the Senate bill. According to a survey by the American
Association of Health Plans about one-third of the patients in HMO's
no longer have to get permission to go to a dermatologist, allergist,
cardiologist or orthopedist.
Widely disliked by physicians and patients alike
that require physicians to get permission in advance prior to admitting
a patient to a hospital or perform a medical procedure is one profound
shift that moves away from the rules. The nearly 10,000 procedures
for which physicians had to get approval, Health Partners, Inc., a
Minnesota-based HMO, five years started to eliminate. The list had
been reduced to fewer than 100 as of a year ago.
Unless a company offered its workers a "point-of-service"
alternative that would allow them to go to a physician of their choice,
Health Partners then announced it would no longer sell coverage to
George C. Halvorson, president and chief executive
of Health Partners said, "We did that because our surveys indicated
consumers wanted choice, and we wanted to promote choice. This was
a market response."
The Association of American Physicians and Surgeons
(AAPS) is sending out an alert to millions of patients across the
nation warning the "Patients’ Bill of Rights" is, in reality, a "Bill
of Goods and that premiums could escalate 20 percent or more."
The legislation is not about "heath care" warn
the physicians but is about money and "about politicians getting in
bed with the trial lawyers so that the lawyers can get their mitts
on more lawsuits and the politicians can rake in $12.4 million in
campaign donations from the trial lawyers."
"We're planning on raising premiums by 20 percent
to start," and that is only the beginning, an insurance company executive
has told the AAPS.
Reference: Wes Vernon, "HMO Lawsuit Bill Will
Make You Pay More for Insurance," NewsMax.com, July 13, 2001; Amy
Goldstein, "Senate's Health Care Bill Lags Behind Some HMO's," The
Washington Post, July 1, 2001.
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