GOP Weakens Democrats’ HMO Bill

WASHINGTON —  Republican senators Tuesday wiped out key provisions of a Democratic bill to give patients more leverage in dealing with their managed health plans.

The sharply partisan debate diminished the chances that a consensus would be reached before the end of the year, all but guaranteeing that the issue will be fought out in next year’s election campaign.

Among the first provisions to be stripped from the Democratic bill, by a vote of 52 to 48, were proposals to allow women to use obstetrician-gynecologists as their primary care doctors and to prohibit health plans from sending women home after mastectomies until the patient and her doctor deemed her ready. However, Republicans quickly said they would propose restricting “drive-through mastectomies.”

“This was truly an opportunity lost,” said Sen. Mary Landrieu, (D-La.), one of several female Democratic senators who led the fight for the measure, which was endorsed by the American College of Obstetricians and Gynecologists.

“For many women, their only doctor is their obstetrician-gynecologist . . . and for the Republicans to say you can’t have your gynecologist as your primary care physician is a sad day,” Landrieu said.

Also left on the cutting-room floor was a definition of “medical necessity,” a common phrase in insurance contracts to describe services that health plans must cover. The Democratic version of the bill would have deemed a test or treatment medically necessary if it was consistent with generally accepted principles of medical practice.

The Republicans replaced it with a provision requiring that health plans offer enrollees the right to appeal denials of care to a doctor within the health plan and to an independent medical reviewer.

Sen John H. Chafee (R-R.I.) broke with his party to vote against the GOP amendment, saying it would render many appeals “meaningless.”

Citing cases where a health plan’s definition of medical necessity limited the ability of doctors to effectively treat patients, Chafee said: “Boy, talk about putting the fox in charge of the chicken coop. This is it.”

The Republican version would allow insurers to continue to determine what services must be covered, said Sen. Dianne Feinstein, (D-Calif.), citing language in an insurance policy from a Missouri company. That policy says the insurer “will have sole discretion to determine whether care is medically necessary. The fact that the care has been recommended, provided, prescribed or approved by a physician will not establish that the care is medically necessary.”

Defending their provision, Republicans said the Democrats’ proposal would require plans to cover virtually any medical practice. That could undermine managed care, which attempts to hold down costs by putting limits on the use of expensive treatments and services.

Republicans also added a poison pill to the Democratic version of the bill--a provision that would block it from taking effect unless it would not raise health insurance costs by more than 1% a year or cause more than 100,000 people to lose their health insurance. Analysts said these tests would be all but impossible to meet.

Also eliminated late Tuesday was a Democratic amendment that would make the Republican plan apply to all 161 million Americans with private health insurance. The Republican bill’s provisions vary widely in who would be covered, depending on the type of health insurance a person carries. The Republicans also voted down a Democratic amendment that would guarantee all Americans the right to go to the nearest emergency room for care and have their treatment covered. However, GOP senators will offer their own version of the provision today.

The Democratic version of the bill has the support of an array of physician groups, including the American Medical Assn., as well as consumer groups. The Republicans have drafted a competing version favored by managed health care companies and employers--although those groups would prefer no legislation at all.

The Senate plans final votes on both versions on Thursday.

*

Times staff writer Stephen Fuzesi contributed to this report.