Spurred by Public’s Complaints, Congress Offers Managed-Care Cures
Reacting to mounting public dissatisfaction with managed health care, Congress is considering at least 10 proposals to regulate health insurance plans with hearings beginning this week.
The most controversial proposal would broaden workers’ rights to bring medical malpractice lawsuits against managed-care companies--and, potentially, the employers who contract with them. Other proposals would require health plans to have a consumer ombudsman and grievance procedures when patients are denied care.
Bolstering the campaign is a presidential health-care commission, which is conducting its final day of deliberations today and is expected to recommend a “consumer bill of rights” that, for example, would require managed-care plans to pay for most emergency room visits.
The nation’s largest businesses, fearful that any such measures would mean higher health insurance costs for them, are mounting a massive opposition campaign combining advertising with lobbying both at the grass-roots level and in Washington.
“Is this going to improve quality or is it going to micromanage plans, drive health costs up and leave fewer people with insurance?” asked Richard Smith, vice president for health policy at the American Assn. of Health Plans.
Many analysts believe that business has good cause for alarm.
“It’s a very good issue for members of Congress,” said health policy expert Robert Blendon, a professor at Harvard University. “It’s a chance to be responsive to a very real middle-class issue.”
“There’s been an apparent decline in consumer confidence in the health-care system and there’s also a tremendous amount of publicity that is often negative about managed care,” said Frank McArdle, director of the Washington office of Hewitt Associates, a health-care consulting firm. “From a legislator’s standpoint, it means your constituents aren’t happy and the first instinct is to listen to your constituents.”
Managed-care plans, which include health maintenance organizations, preferred provider organizations and point-of-service plans, control costs by limiting access to specialists and expensive tests. Such plans now cover at least 60% of people who purchase their health insurance through private employers, according to the Congressional Budget Office.
Proposals percolating in Congress would:
* Mandate that managed-care plans cover certain benefits such as emergency care and experimental treatments.
* Establish independent appeals of decisions by managed-care plans to deny benefits.
* Require plans to divulge information about their contracts with health-care providers in their networks.
But the bill that most concerns business groups and managed-care plans would make it far easier for workers to sue managed-care companies and, potentially, their employers for medical malpractice. That would give patients a weapon that they now lack when plans deny treatment or refuse to pay claims.
The bill, which is slated for its first congressional hearing Thursday, is sponsored by Rep. Charlie Norwood (R-Ga.), a conservative Southern dentist. In the Senate, Alfonse M. D’Amato (R-N.Y.), is championing a similar bill.
“Medical malpractice is the ultimate safeguard a patient has and federal laws have preempted all the state protections and replaced it with nothing,” said Norwood, who has nearly 170 co-sponsors for his bill.
Norwood’s legislation would make major changes in the obscure but powerful Employee Retirement Income Security Act, which exempts self-insured health plans from state health insurance regulation. That exemption was designed to help large multi-state companies, which insure their own employees, by letting them meet a consistent set of federal regulations rather than forcing them to abide by 50 different sets of state laws.
The courts have sent mixed signals on whether HMOs can be sued for medical malpractice.
But self-insured plans, which generally are operated by large and mid-sized companies, are exempt. Business groups said that allowing lawsuits against self-insured plans would open up the employer who contracts with the HMO to be sued as well.
“The employer would have to look over the shoulder of the HMO and would be liable for all the things that the insurer and the HMO have control over,” said Anthony Knettel, director of health policy for the ERISA Industry Committee, which represents Fortune 500 companies.
Beyond Norwood’s bill, several others would open managed-care plans to various consumer protections--such as an appeals process for denial of care--but not to malpractice suits.
“Too many managed-care plans and other insurance companies have decided that the best route to higher profits is by denying patients the health care they need,” said Sen. Edward M. Kennedy (D-Mass.), who is sponsoring one health-care reform bill.
The 34-member presidential Commission on Quality avoided the politically charged ERISA issue, opting instead to recommend guidelines in somewhat less controversial areas such as consumer information on access to specialists.
Among the “consumer rights” that the presidential commission has proposed:
* Regular access to specialists for treatment of chronic conditions without need for a referral from a primary-care physician each time.
* Information for patients about how a plan’s financial arrangements with doctors may affect the doctors’ treatment recommendations.
* Guarantees that health plans could not threaten to end their contracts with doctors who tell patients that more effective treatments are available outside the plan.
* Confidentiality of patients’ medical records.
