Copyright 1999 Federal News Service, Inc.
Federal News Service
JUNE 24, 1999, THURSDAY
SECTION: IN THE NEWS
LENGTH:
490 words
HEADLINE: PREPARED STATEMENT OF
THE
HONORABLE JOHN D. DINGELL
BEFORE THE HOUSE COMMERCE
COMMITTEE
SUBCOMMITTEE ON HEALTH AND ENVIRONMENT
SUBJECT - HEARING ON
AMERICA'S HEALTH: PROTECTING PATIENTS
WITH A STRONG APPEALS PROCESS
BODY:
Today the Health and Environment
Subcommittee will discuss the cornerstone of any patient protection legislation,
the external appeals process. I would like to thank Chairman Bliley and
Subcommittee Chairman Bilirakis for holding a hearing on a topic that is so
fundamental to managed care reform.
A timely, independent,
and enforceable internal and external appeals process would help to restore
faith in the health care system on behalf of all parties. People would know that
if their doctors' treatment recommendations were denied, they would be entitled
to an impartial opinion from medical experts. A fair external appeals process
would reinforce the behavior of health plans that made good medical decisions
rather than insurance decisions. Most importantly, an external appeals process
would help patients get the health care they need, when they need it. As part of
this debate we must discuss medical necessity, the key component of any appeals
process. If this process is to settle disputes between a health plan and your
doctor on what treatment you get, then we want the decision to be based on the
doctor's best medical judgment, not the health plan's. We do not want these
independent experts to be bound by the way the plan defines "medical necessity,"
which in some cases is whatever the plan says it is. A review conducted in this
narrow bureaucratic fashion would be a sham.
These reviewers should
determine if the treatment is appropriate based on the "professional standard of
care" at the time and taking into consideration the individual circumstances of
the patient. The professional standard is not a static concept, but instead is a
way of assessing a provider's conduct toward individual patients in light of the
current state of knowledge of medical care within the profession. We don't want
anyone to get "cookbook" medicine, particularly if the cookbook is written by
bureaucrats.
An external appeals process that fails to meet this standard
will not do the job. A weak or biased system would actually make life worse for
patients by creating another layer between a plan's internal review process and
a patient's last resort, the legal system.Finally, a strong external appeals
process is no good without enforcement. A good external appeals process should
help to reduce the number of court cases by ensuring that more patients receive
the care they need, but it can do nothing to help patients for whom further
treatment would be futile. For those patients who have died or have been
permanently harmed, we must see that health plans, just like any other
organization, are held accountable for their actions.
Chairman Bliley and
Subcommittee Chairman Bilirakis, thank you again for holding this hearing. I
hope that this Committee will soon mark up managed care reform
legislation that includes a strong external appeals process, as well as other
protections patients want and deserve.
END
LOAD-DATE: June 25, 1999 
