Legislators call for managed care reform

Pharmaceutical Representative

A group of senators reintroduced a bipartisan managed care reform bill that calls for guaranteeing "patient protections" and establishing patient complaint procedures, as well as levying fines against providers with chronic compliance problems.

A group of senators reintroduced a bipartisan managed care reform bill that calls for guaranteeing "patient protections" and establishing patient complaint procedures, as well as levying fines against providers with chronic compliance problems.

The Promoting Responsible Managed Care Act of 1999 was unveiled on Feb. 4 by its authors, Sens. John Chafee (R-RI) and Bob Graham (D-FL), and fellow senators from both parties: Joe Lieberman (D-CT), Arlen Specter (R-PA), Max Baucus (D-MT), Charles S. Robb (D-VA), and Evan Bayh (D-IN).

In a summary of their proposal, they said that "there is growing anxiety among many Americans that insurance health plan accountants - not providers - are determining what services and treatments they receive."

The same day the bipartisan legislation was introduced, Senate Finance Committee Chairman William V. Roth (R-DE) and ranking Democrat Sen. Daniel Patrick Moynihan (D-NY) announced that their committee would hold meetings not to debate legislation but to gather information on the issue.

In a joint statement, Roth and Moynihan said they plan to take a "fresh look at all of the issues" and hope to find a "bipartisan consensus solution" to managed care reform.

"Under this bill, doctors and other health care providers would end up providing more medical care, not better medical care," said Chip Kahn, president of the Health Insurance Association of America, Washington.

"As a result, health care costs would go up even more, and so would health-insurance premiums," he said.

Four provisions

Four key provisions of the Managed Care Act include protections for enrollees, enforcement, patient appeals and consumer access to information.


•Â Patient protections. Plans would have to pay for services that a doctor deems medically necessary and that the provider covers as a benefit. Emergency services would be covered based on the "prudent layperson" standard and would include reimbursement for costs immediately following emergency care. Plans would be banned from offering financial incentives to encourage doctors to limit "medically necessary" care.


•Â Patient appeals. Patients could appeal a plan's decision not to cover emergency services; to deny, limit or end benefits; or to deem certain types of care unnecessary. Appeals of severe complaints or those involving significant monetary damages would be determined by an outside party in binding arbitration. The plan would pay the costs.


•Â Enforcement. The Secretaries of Labor and Health and Human Services would be given the power to prevent managed care plans from denying medically necessary care to enrollees. Plans that unreasonably deny coverage or delay benefits to patients and thus put patients' lives in danger could receive fines up to $50,000 per patient for first-time offenses or as much as $250,000 for plans with a pattern of violations.

Patients could sue providers for economic losses suffered by the wrongful denial of coverage. "Economic loss" means lost wages or other benefits related to employment, medical expenses and business or employment opportunities. No limits would be set on awards, and courts could award attorneys' fees. Also, plaintiffs could sue in federal court.


•Â Consumer information. Consumers would be given information on enrollee satisfaction, benefits, cost-sharing, access to services and grievance and appeals policies, among others, to determine which provider is best for them.

Last year, managed care reform died in the Senate. However, Sen. Chafee feels confident this year about the bill becoming law. Voters "want action, not gridlock," he said. In 1999, Democrats gained five more seats in the House, he noted, the number of votes by which the Patient's Bill of Rights was defeated last year. Furthermore, new House Speaker Dennis Hastert (R-IL) is an advocate of managed care reform and could help rally support in the House. PR