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Search Terms: patients bill of rights, House or Senate or Joint

Document 203 of 268.

MAY 13, 1999, THURSDAY

SECTION: IN THE NEWS

LENGTH: 1914 words

HEADLINE: PREPARED STATEMENT OF
WILLIAM E. FLYNN, III
ASSOCIATE DIRECTOR FOR RETIREMENT AND INSURANCE
U.S. OFFICE OF PERSONNEL MANAGEMENT
BEFORE THE HOUSE COMMITTEE ON GOVERNMENT REFORM
SUBCOMMITTEE ON CIVIL SERVICE
SUBJECT - OPM'S POLICY GUIDANCE FOR FEHB CONTRACT YEAR 2000

BODY:

MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
THANK YOU FOR INVITING ME TODAY TO DISCUSS OPM'S GOALS FOR UPCOMING CONTRACT NEGOTIATIONS WITH HEALTH PLANS ELIGIBLE TO PARTICIPATE IN THE FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM DURING THE YEAR 2000.
SPECIFICALLY, YOU HAVE ASKED HOW THE POLICIES OPM COMMUNICATED TO HEALTH PLANS IN LAST MONTH'S CALL LETTER INVITING PROPOSALS FOR RATE AND BENEFIT CHANGES WILL IMPACT PREMIUM RATES AND THE QUALITY OF BENEFITS CURRENTLY AVAILABLE. WE ARE CONFIDENT THAT THE PROGRAM WILL MAINTAIN ITS ABILITY TO PROVIDE HIGH-QUALITY, AFFORDABLE HEALTH CARE FOR ITS APPROXIMATELY 9 MILLION MEMBERS. IN ADDITION, IT WILL REMAIN AS A MODEL EMPLOYER-BASED HEALTH BENEFITS PROGRAM THAT RELIES ON COMPETITION AND CONSUMER CHOICE.IN ISSUING THE CALL LETTER EACH YEAR, OUR PURPOSE IS TO COMMUNICATE OPM'S EXPECTATIONS FOR CONTRACTING OUTCOMES. OUR GUIDANCE LEAVES AS MUCH FLEXIBILITY AS POSSIBLE FOR EACH PLAN TO MAKE PROPOSALS THAT WILL ACHIEVE THE DESIRED OUTCOMES FOR ENROLLEES. ACCORDINGLY, EACH HEALTH PLAN'S BENEFITS AND RATES ARE ULTIMATELY THE PRODUCT OF BILATERAL NEGOTIATIONS. OPM VALUES THIS OPPORTUNITY TO PARTNER WITH HEALTH INSURERS TO OFFER ENROLLEES ACCESS TO QUALITY CARE AT AFFORDABLE RATES.
AS A RESPONSIBLE EMPLOYER-SPONSOR OF A HEALTH INSURANCE PROGRAM, OPM'S ADMINISTRATION OF THE PROGRAM HAS BEEN, AND WILL CONTINUE TO BE, PROGRESSIVE. MANY OF THE IMPROVEMENTS WE HAVE CHAMPIONED HAVE BEEN ACHIEVED WITH MINIMAL, IF ANY IMPACT ON PREMIUMS. SINCE THE EARLY 1990'S, WE HAVE ENSURED THAT ALL PLANS INCLUDE A COMPREHENSIVE CORE OF MEDICAL BENEFITS, SO THAT PARTICIPANTS CAN BE ASSURED OF COVERAGE FOR BASIC HEALTH NEEDS. ALL PLANS NOW INCLUDE MECHANISMS TO MANAGE CARE WITHOUT JEOPARDIZING QUALITY. WE HAVE CONTINUALLY IMPROVED INFORMATION AND RELATED MATERIALS TO ENCOURAGE PARTICIPANTS TO BE INFORMED CONSUMERS. MORE RECENTLY, WE HAVE ENCOURAGED HEALTH PLANS TO BECOME ACCREDITED. OVER THE PAST TWO YEARS, IN COLLABORATION WITH CARRIERS, WE HAVE UNDERTAKEN FULL IMPLEMENTATION OF PRESIDENT CLINTON'S PATIENTS' BILL OF RIGHTS.FOR A TOTAL COST OF LESS THAN $10 PER YEAR FOR EACH POLICYHOLDER,
PARTICIPANTS IN THE PROGRAM RECEIVE A BROAD RANGE OF PROTECTIONS.
FOR 1999, WE ADDED THE FOLLOWING:
- USE OF THE "PRUDENT LAYPERSON" STANDARD FOR ACCESSING EMERGENCY CARE;
- DIRECT ACCESS TO QUALIFIED PROVIDERS FOR ROUTINE AND PREVENTIVE WOMEN'S HEALTH SERVICES;
- DIRECT ACCESS TO SPECIALISTS FOR PEOPLE UNDERGOING TREATMENT PLANS;
- ACCESS TO NEEDED SPECIALISTS, EVEN IF THEY ARE OUTSIDE OF THE PLAN'S NETWORK; AND
- MANY IMPORTANT PATIENT PROTECTIONS SURROUNDING INFORMATION DISCLOSURES ON PLAN CHARACTERISTICS AND PERFORMANCE, PROVIDER NETWORK CHARACTERISTICS, AND CARE MANAGEMENT
THE SIGNIFICANT CONTRACTING INITIATIVES OPM IDENTIFIED FOR CONTRACT
YEAR 2000 INCLUDE:
- THE PATIENTS' BILL OF RIGHTS; - QUALITY HEALTHCARE; - MORE FAMILY-CENTERED HEALTHCARE; - ENHANCED CUSTOMER SERVICE; - CLARIFYING PROVIDER CONTRACTS; - IMPLEMENTATION OF THE DOD/FEHB DEMONSTRATION PROJECT; AND - Y2K COMPLIANCE. PATIENT'S' BILL OF RIGHTS
THE 1999 CALL LETTER INCLUDES TWO ENCLOSURES THAT SUMMARIZE
INFORMATION DISCLOSURES AND BENEFIT CHANGES PLANS SHOULD ALREADY HAVE IN PLACE FOR 1999, AND NEW DISCLOSURES AND BENEFITS FOR YEAR 2000 CONTRACTS. WE EXPECT THE PROGRAM-WIDE COST OF IMPLEMENTING THE REMAINING FEATURES WILL BE SMALL, AS PLANS HAVE PREVIOUSLY COMPLETED MANY OF THE REQUIREMENTS.
DURING NEGOTIATIONS THIS SUMMER, OPM WILL WORK WITH EACH PLAN TO DEVELOP BROCHURE LANGUAGE THAT DESCRIBES THE INFORMATION PLAN MEMBERS ARE ENTITLED TO RECEIVE--WHETHER IN ADVANCE OF ENROLLMENT DECISIONS OR UPON REQUEST--AND THE MEANS FOR ACCESSING IT. OUR GOAL IS TO HAVE A POSITIVE IMPACT ON CARE BY ENABLING INDIVIDUALS TO MAKE BETTER PLAN COMPARISONS AND TO ASSESS PROVIDER QUALIFICATIONS AND AVAILABLE TREATMENT OPTIONS.
LAST YEAR'S CALL LETTER RECOGNIZED THAT CERTAIN PATIENTS' BILL OF RIGHTS BENEFIT CHANGES MIGHT REQUIRE CHANGES THAT PLANS COULD NOT IMMEDIATELY EFFECT. ACCORDINGLY, OPM IS NOW ASKING PLANS TO SPECIFY COMPLIANCE STRATEGIES FOR TRANSITIONAL CARE. THIS BENEFIT PROTECTS PLAN MEMBERS UNDERGOING TREATMENT FOR CHRONIC OR DISABLING CONDITIONS (OR IN THE SECOND OR THIRD TRIMESTER OF PREGNANCY) AT THE TIME THEY INVOLUNTARILY CHANGE HEALTH PLANS, OR AT THE TIME THEIR PROVIDER IS TERMINATED BY THE PLAN FOR REASONS OTHER THAN CAUSE. IT ALLOWS PLAN MEMBERS TO CONTINUE SEEING THEIR SPECIALTY PROVIDERS FOR UP TO 90 DAYS (OR THROUGH COMPLETION OF POSTPARTUM CARE) AT THE SAME COST THE MEMBER WAS INCURRING PREVIOUSLY. ALSO, HEALTH PLANS MUST ESTABLISH PROCEDURES TO ALLOW PATIENTS TO REVIEW AND OBTAIN COPIES OF THEIR MEDICAL RECORDS ON REQUEST AND REQUEST THAT A PHYSICIAN AMEND, OR ALLOW THEM TO APPEND, A RECORD THEY BELIEVE IS INACCURATE, IRRELEVANT, OR INCOMPLETE.
QUALITY HEALTHCARE
QUALITY HEALTHCARE REFERS TO THE DEGREE TO WHICH HEALTH SERVICES FOR INDIVIDUALS AND POPULATIONS INCREASE THE LIKELIHOOD OF DESIRED HEALTH OUTCOMES AND ARE CONSISTENT WITH CURRENT PROFESSIONAL KNOWLEDGE. MOREOVER, NOW THAT EVERY TYPE OF HEALTH PLAN USES MECHANISMS TO MANAGE UTILIZATION, QUALITY HEALTHCARE MUST ALSO ENCOMPASS HOW A PLAN MEETS ITS MEMBERS' NONCLINICAL NEEDS AND EXPECTATIONS. PLAN PERFORMANCE MEASUREMENTS BOLSTER MARKET COMPETITION AND INFORMED CHOICE.

OUR CALL LETTER LISTS QUALITY ASSESSMENT METHODS ON WHICH OPM EXPECTS HEALTH PLAN COOPERATION, INCLUDING:
- STRONGLY ENCOURAGING PLANS TO SEEK ACCREDITATION FROM AN EXTERNAL ORGANIZATION;
- ASKING PLANS THAT REPORT ON STANDARDIZED PERFORMANCE MEASURES IN THE HEALTH PLAN AND EMPLOYER DATA INFORMATION SET (HEDIS) FOR OTHER PURCHASERS, TO SHARE REPORTS WITH OPM IN 2000; OPM MAY ASK NON- REPORTING PLANS TO REPORT HEDIS-LIKE DATA;
- ASKING HEALTH PLANS TO PARTICIPATE IN OUTCOME MEASURES RESEARCH SUCH AS THE ASTHMA TREATMENT PROJECT THAT OPM CONDUCTED IN COOPERATION WITH SEVERAL HEALTH PLANS AND THE FOUNDATION FOR ACCOUNTABILITY (FACCT); AND
- CONTINUING USE OF THE CONSUMER ASSESSMENT OF HEALTH PLANS STUDY (CAHPS) ADULT AND CHILD QUESTIONNAIRES, UNDER NATIONAL COMMISSION FOR QUALITY ASSURANCE (NCQA) PROTOCOLS, TO MEASURE FEHB CUSTOMER SATISFACTION.
FAMILY-CENTERED CARE
LAST YEAR, THE VICE PRESIDENT'S 7TH ANNUAL FAMILY REUNION FOCUSED ON FAMILIES AND HEALTH. AS A PARTICIPANT IN THAT EVENT, THE INSTITUTE FOR FAMILY-CENTERED CARE PROMOTED THE IDEA THAT THE FAMILY HAS SIGNIFICANT INFLUENCE OVER AN INDIVIDUAL'S HEALTH AND WELL-BEING AND, THEREFORE, FAMILIES MUST BE SUPPORTED IN THEIR ROLES AS CARE GIVERS AND DECISION MAKERS. THIS INSPIRED A DISCUSSION OF FAMILYFOCUSED HEALTH CARE AT THE FEHB CARRIER CONFERENCE LAST FALL AND ULTIMATELY OPM CONTRACTED WITH THE GALLUP ORGANIZATION TO CONDUCT FOCUS GROUPS IN SEVERAL LARGE CITIES TO ASSESS OUR PROGRAM FROM A FAMILY-FOCUSED PERSPECTIVE.
FOLLOWING UP ON THESE INITIATIVES, THE CALL LETTER EXPLAINS THAT OPM EXPECTS HEALTH PLANS NOT ONLY TO FOLLOW RECOMMENDATIONS OF RECOGNIZED MEDICAL AUTHORITIES CONCERNING CHILDHOOD IMMUNIZATIONS AND HEALTH SCREENINGS BUT ALSO TO CONSIDER RISK ASSESSMENT AND FAMILY HISTORY WHEN MAKING COVERAGE DETERMINATIONS. NOTING THE WIDE INTEREST IN DENTAL AND VISION COVERAGE, OPM URGES PLANS TO OFFER COVERAGE TO FEHB MEMBERS AS NON-FEHB BENEFITS WHILE OPM LOOKS AT OPTIONS IN THESE AREAS FOR THE FUTURE. IN RESPONSE TO ISSUES FOCUS GROUPS RAISED ABOUT PLAN ADMINISTRATION, WE ENCOURAGE PLANS TO PLAY A POSITIVE ROLE AS FACILITATOR IN BEHALF OF THEIR MEMBERS AND TO DEVELOP REFERRAL PROCEDURES THAT MINIMIZE DISRUPTION TO ENROLLEES. WE SUGGEST THAT WELL-ESTABLISHED PATIENT EDUCATION PROGRAMS AND CLEARLY WRITTEN BENEFIT EXPLANATIONS MAY PROMOTE MORE REALISTIC MEMBER EXPECTATIONS. FAMILY-CENTERED CARE TAKES A COLLABORATIVE EFFORT BETWEEN THE PATIENT, PROVIDER, AND HEALTH PLAN. OPM INVITES EVERY PLAN TO REPORT ACTIVITIES IN THIS AREA AND TO SUBMIT EXAMPLES OF FAMILY-CENTERED COMMUNICATIONS FOR ENROLLEES.
CUSTOMER SERVICE
THE PRESIDENT AND VICE PRESIDENT HAVE MADE PLAIN LANGUAGE IN GOVERNMENT WRITING A TOP PRIORITY FOR FEDERAL AGENCIES. IT SAVES TIME, EFFORT, AND MONEY, AND SENDS A CLEAR MESSAGE ABOUT WHAT THE GOVERNMENT IS DOING. IN JANUARY, OPM ANNOUNCED AN INITIATIVE TO REWRITE HEALTH PLAN BROCHURES IN PLAIN LANGUAGE AND, IN COLLABORATION WITH HEALTH PLAN REPRESENTATIVES, IS DEVELOPING GUIDELINES FOR WRITTEN COMMUNICATIONS. PLANS CAN ANTICIPATE THESE PRODUCTS IN LATE SPRING. WE ARE VERY EXCITED ABOUT THIS PROJECT. IT WILL IMPROVE THE CLARITY OF OUR BROCHURES AND RELATIONSHIPS WITH CUSTOMERS.
THE SECOND ITEM UNDER CUSTOMER SERVICE ADDRESSES DEFICIENCIES BY SOME PLANS IN PROCESSING ELECTRONIC ENROLLMENTS LAST YEAR. WE REQUIRE THAT PARTICIPATING PLANS HAVE THE CAPABILITY TO PRODUCE BROCHURES, TO RECEIVE AND SEND ELECTRONIC INFORMATION, AND ACCEPT ENROLLMENT INFORMATION ELECTRONICALLY. THE GUIDANCE STRESSES THAT THE ABILITY TO MEET THESE REQUIREMENTS IS AN IMPORTANT ELEMENT IN EVALUATING A PLAN'S PERFORMANCE.
PROVIDER CONTRACTS
THIS SECTION OF THE CALL LETTER CLARIFIES TWO ISSUES RELATING TO PROVIDER REIMBURSEMENT UNDER FEE-FOR-SERVICE HEALTH PLANS. THERE HAS BEEN ON-GOING CONCERN IN THE MEDICAL COMMUNITY ABOUT PAYMENT SCHEMES THAT CREATE FEE DISCOUNTS FOR PAYERS WHO ARE NOT ENTITLED TO THEM. AN INVESTIGATION BY OPM'S INSPECTOR GENERAL FOUND NO EVIDENCE OF THESE PRACTICES IN THE FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM. NEVERTHELESS, WE EXPECT PLANS THAT SECURE FEE DISCOUNTS THROUGH INTERMEDIARIES WILL CONTINUE TO ENSURE THAT DISCOUNTS ARE CONSISTENT WITH CONTRACTS BETWEEN THE VENDOR AND PROVIDER NETWORKS, AND ARE PROPERLY DISCLOSED.
THE SECOND ISSUE INVOLVES A PROVISION IN LAW THAT GUARANTEES ACCESS TO CERTAIN NON-PHYSICIAN PROVIDERS WHO ARE QUALIFIED TO RENDER A COVERED SERVICE. PUBLIC LAW 105-266 AMENDED THIS LAW TO CLARIFY THAT NOTHING PREVENTS HEALTH PLANS FROM PROVIDING BENEFITS FOR SERVICES RENDERED BY PROVIDERS OTHER THAN THOSE LISTED IN STATUTE. WE ENCOURAGE PLANS TO PROVIDE ACCESS TO NON-PHYSICIAN PROVIDERS WHO ARE QUALIFIED TO PROVIDE COVERED SERVICES, SUCH AS AUDIOLOGISTS OR PHYSICIAN ASSISTANTS, WHEN IT IS APPROPRIATE AND COST EFFECTIVE TO DO SO.
DOD/FEHB DEMONSTRATION PROJECT
THE CALL LETTER REMINDS PLANS THAT WE ARE IMPLEMENTING A DEMONSTRATION PROJECT THAT WILL PERMIT UP TO 66,000 MEDICARE-ELIGIBLE MILITARY RETIREES AND RELATED BENEFICIARIES TO ENROLL IN THE FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM BEGINNING IN JANUARY 2000, AND CONTINUING THROUGH THE END OF 2002. THE PROJECT WILL INVOLVE ALL OPEN FEE-FOR- SERVICE PLANS AND HMOS THAT OPERATE WITHIN THE EIGHT DEMONSTRATION SITES. AFFECTED HEALTH PLANS WILL ESTABLISH SEPARATE RISK POOLS FOR MILITARY ENROLLEES, AND WILL SUBMIT A SEPARATE PREMIUM PROPOSAL FOR THE MILITARY GROUP. BENEFITS WILL BE THE SAME.
Y2K COMPLIANCE
THE CALL LETTER REMINDS PLANS THAT THE 1999 CONTRACT REQUIRES PLANS TO REPORT Y2K COMPLIANCE STATUS ALONG WITH THEIR BENEFIT AND RATE PROPOSALS ON MAY 31, 1999. WE FURTHER ADVISE PLANS THAT THEY SHOULD ANTICIPATE INCREASED DEMANDS BECAUSE OF PARTICIPANT APPREHENSION ABOUT THE YEAR 2000, AND TO TAKE STEPS TO ALLAY CONSUMER CONCERNS. WE EXPECT PLANS WILL HAVE PROCEDURES IN PLACE TO RELAX USUAL RESTRICTIONS ON ACCESS TO PRESCRIPTION REFILLS AND OTHER SERVICES.
THIS CONCLUDES MY OVERVIEW OF THE OBJECTIVES WE HOPE TO ACHIEVE FOR CONTRACT YEAR 2000. THE ANSWERS TO THE QUESTIONS CONTAINED IN THE LETTER INVITING MY TESTIMONY ACCOMPANY THIS STATEMENT. I WILL BE GLAD TO ANSWER OTHER QUESTIONS YOU HAVE NOW.
END

LOAD-DATE: May 18, 1999

Document 203 of 268.


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