Congress debates managed care

Pharmaceutical Representative

Congress will review two managed care plans that intend to outline patients' health care rights this fall.

Congress will review two managed care plans that intend to outline patients' health care rights this fall.

The goal for legislators will be to find common ground on the terms of what has been referred to as a "patient bill of rights." However, considering that the plans have been submitted by opposing political camps during a time when many members of Congress are up for re-election, compromise may not be a top priority on the Hill this fall.

The Democrats submitted their plan, spearheaded by Thomas Daschle (D-SD), first and the Republicans followed suit with their plan, headed by Sen. Don Nickles ( R-OK), shortly thereafter. Although the plans concur on some points, they differ enough on most other issues to make compromise an imposing challenge.

Points on which the plans agree include ensuring a patient's right to see out-of-plan doctors if patients are willing to pay additional fees for the privilege, allowing women to see OB/GYNs without having to wait for a referral and requiring health maintenance organizations to pay for emergency care.

The Democrats' plan would allow patients to sue managed care plans for damages if they are hurt by the managed care plan's decision not to pay for their care. It is also comprehensive, and would cover the lives of 150 million Americans, including those not covered by Medicare or Medicaid.

The Republicans' less costly and more HMO-friendly plan would encourage mediation in patient-plan disputes over care decisions, and would not contradict legal precedents. It would cover the approximately 48 million people who are enrolled in health care plans insured by employers.

Not surprisingly, HMOs are in favor of the Republican version of the patient bill of rights. However, Donna Shalala, Secretary of the Department of Health and Human Services said she disagreed with the bill because of the limited number of people it would cover, its weak stance on appeals and lawsuits and its inability to guarantee patients the right to see a specialist without going through a gatekeeper.

Although Congress had scheduled to review the plans before its August recess, an inability to compromise caused Senators to postpone the debate until their return. PR