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Our bill extends many of the same rights and protections to these individuals and their families that Americans

[Page: S920]  GPO's PDF
in state-regulated plans already enjoy. For the first time, they will be guaranteed the right to talk freely and openly with their doctors about their treatment options without being subject to ``gag clauses'' that limit communications. They will be guaranteed coverage for emergency room care th at a ``prudent layperson'' would consider medically necessary without prior authorization from their health plan. They will be able to see their OB-GYN or pediatrician without a referral from their plan's ``gatekeeper,'' and they will have the option of seeing a doctor who is not a part of their HMO's network. They will also have some assurance of continuity of care if their health plan terminates its contract with their doctor or hospital.

   Moreover, all patients will be given the right to review their medical records and will have added protections to ensure that this information will be kept confidential. Finally, insurers will be prohibited from collecting or using predictive genetic information about a patient to deny coverage or set premium rates.

   Mr. President, the states are way ahead of the federal government in the area of insurance reform, a nd the State of Maine has already enacted many of these same consumer rights and protections--a ban on gag clauses, a prudent layperson definition for emergency care, a nd direct access to OB/GYNs. Our bill would extend these and other rights to the nearly 220,000 Maine citizens in health plans that are not subject to state regulation and who currently do not enjoy these protections.

   A key provision of our bill would give all 125 million Americans in employer-sponsored plans assurance that they will get the care th at they need, when they need it. This includes 535,735 people in Maine who are in fully-insured ERISA plans. For the first time, these individuals will be entitled to clear and complete information about their health plan--about what it does and does not cover, about any cost-sharing requirements, and about the plan's providers. Helping patients understand their coverage before they need to use it will help to avoid coverage disputes later.

   The goal of any patient protection legislation should be to solve disputes about coverage up from, when the care is needed. Not months, or even years later, in a court room.

   Our bill would accomplish this goal by creating both an internal and external review process. First, patients or doctors who are unhappy with an HMO's decision could appeal it internally through a review conducted by individuals with ``appropriate expertise'' who were not involved in the initial decision. Moreover, this review would have to be conducted by a physician if the coverage denial is based on a determination that the service is not medically necessary or is an experimental treatment. Patients could expect results from this review within 30 days, or 72 hours in cases when delay poses a serious risk to the patient's life or health.

   Patients turned down by this internal review would then have the right to a free, external review by medical experts who are completely independent of their health plan. This review must be completed within thirty days--and even faster in a medical emergency or when delay would be detrimental to the patient's health. Moreover, the decision of these outside reviewers is binding on the health plan, but not on the patient. If the patient is not satisfied, they retain the right to sue in federal or state court for attorneys' fees, court costs, the value of the benefit and injunctive relief.

   Our bill differs from the Democrats' bill in a fundamental respect: it places treatment decisions in the hands of doctors, not lawyers. If your HMO denies you treatment that your doctor believes is medically necessary, you should not have to resort to a costly and lengthy court battle to get the care yo u need. After all, doesn't it make more sense to put medical care in the hands of doctors, not lawyers? You should not have a resort to hiring a lawyer and filing an expensive lawsuit to get the treatment. You just can't sue your way to quality health care. < p>   The purpose of our bill is to solve problems up-front when the care is needed, not months or even years later after the harm has occurred. According to the GAO, it takes an average of 33 months to resolve malpractice cases. One case in the study took 11 years. This does absolutely nothing to ensure a patient's right to timely and appropriate care. M oreover, patients only receive 43 cents out of every dollar awarded in malpractice cases. The rest winds up in the pockets of the trial lawyers and administrators of the court and insurance systems.

   Finally, more lawsuits are certain to mean higher health care co sts. According to the Barents Group of KPMG Peat Marwick, increased lawsuits could drive up premiums as much as 8.6 percent, forcing businesses to pay $94.1 billion ($1,284 per worker) in extra premiums over five years. Close to two million Americans could lose their health insurance next year as increased costs force many employers to eliminate coverage altogether, or to pass on higher premiums and out-of-pocket costs to employees who can't afford them.

   Last fall I met with a group of Maine employers who expressed their serious concerns about the Democrats' proposal to expand liability for health plans and employers. The Assistant Director for Human Resources at Bowdoin College talked about how moving to a self-funded, ERISA plan enabled them to continue to offer affordable coverage to Bowdoin employees when premiums for their fully-insured plan skyrocketed in the late 1980s. Since they self-funded, they have actually been able to lower premiums for their employees, while at the same time, enhance their benefit designs with such features as well-baby care, f ree annual physicals, and prescription drug cards with low copayments. They told me that the Democrats' proposal to expand liability seriously jeopardizes their ability to offer affordable coverage for their employees. Similar concerns were expressed by the Maine Municipal Association, L.L. Bean, Bath Iron Works, and others.

   Mr. President, our bill also contains important provisions to improve health care qu ality and outcomes for all Americans.

   For example, I am particularly pleased that our bill contains the proposal introduced by my colleague from Maine, Senator SNOWE, that prohibits insurers from discriminating on the basis of predictive genetic information.

   Genetic testing holds tremendous promise for individuals who have a genetic predisposition to beat cancer and other diseases and conditions with a genetic link. However, this promise is significantly threatened when insurance companies use the results of such testing to deny or limit coverage to consumers on the basis of genetic information. In addition to the potentially devastating consequences of being denied health insurance on the basis of genetic information, the fear of discrimination may discourage individuals who might benefit from having this information from ever getting tested.

   And finally, our bill will make health insurance more affordable by allowing self-employed individuals to deduct the full amount of their health care pr emiums beginning not in 2003, as in current law, but next year.

   Establishing parity in the tax treatment of health insurance costs between the self-employed and those working for large businesses is a matter of basic equity, and it will also help to reduce the number of uninsured, but working, Americans. It will make health insurance more affordable for the 82,000 people in Maine who are self-employed. They include our lobstermen, our hairdressers, our electricians, our plumbers, and the many owners of mom-and-pop stores that dot communities throughout the state.

   Mr. President, I believe that our plan strikes the right balance as we effectively address concerns about quality and choice without resorting to unduly burdensome federal controls and mandates that would further drive up costs and cause some Americans to lose their health insurance altogether. I urge all of my colleagues to join us in cosponsoring this proposal.

    Mr. FRIST. Mr. President, I rise to voice my support for the bill we are introducing today and to urge my colleagues to pass a strong Patients' Bill of Rights this year. Our Patients' Bill of Rights is a good bill that will improve the quality of health care fo r patients in this country.

[Page: S921]  GPO's PDF

   We have the benefit of starting off in a new Congress. The partisan rhetoric of elections is behind us. Today, we are here to convey our genuine interest to pass managed ca re re form th is year as well as to provide the necessary building blocks to improve health care qu ality.

   Not much attention was given in last year's debate to the many areas of agreement between the Republican and Democratic proposals. It is my hope that we can work together this year in a deliberative, thoughtful manner to pass bipartisan legislation. For example, there is bipartisan support to enact strong patient protection standards including coverage for emergency screening exams and services; allowing continuity of care so that patients may keep their physician, even if he or she is dropped from the plan, during a terminal illness, institutional care or pregnancy; and to prohibit plans from including gag clauses in their contracts. There is also strong consensus that we must require health plans to provide comparative information about their plans and to hold plans accountable for their decisions by allowing patients to appeal coverage denials to an independent medical expert, including expedited reviews, and receive a timely response.

   In addition, I am pleased that many provisions that are in the Senate Republican bill also have received bipartisan support. Our bill last year included the ``Women's Health Research and Prevention Amendments,'' which I also introduced as S. 1722, that passed the Senate unanimously at the end of last year. These programs provide a broad spectrum of activities to improve the quality of women's health; including research, prevention, treatment, education and data collection.

   We must remember that the central focus of this debate--the genesis for the entire debate--is to embark on a national discussion of how we can truly improve real quality of care fo r patients. Our bill this year will again contain two measures which have broad bipartisan support and will greatly improve the quality of health care in this country.

   Title III of our bill prohibits genetic discrimination against individuals in health insurance. Prohibiting genetic discrimination translates into a patient's right to quality care. G enuine quality care me ans that patients and practitioners have the very best information available to them when they make health care de cisions. Patients should not be afraid to benefit from new genetic technologies, or share personal information that has immense potential to improve care an d save lives. This is not a political or partisan issue. Our 49 Republican cosponsors last year, several of our Democratic colleagues, and President Clinton all support enacting legislation to prohibit genetic discrimination.

   Title IV of our bill refocuses the Agency for Health Care Po licy and Research to support our federal efforts to improve health care qu ality through a vigorous research agenda. I also introduced this proposal as a stand alone bill (S. 2208) last year which had broad bipartisan support. Our goal is to enhance the agency to become the driving force of our federal efforts to support the science necessary to provide patients with information about the quality of care th ey receive and to provide physicians with research data to improve health care ou tcomes for their patients.

   There is no question Congress will need to revisit some issues in the managed ca re de bate. However, we will work deliberatively and in a bipartisan manner through our committee work this year to pass comprehensive legislation because we all share the ultimate goal of improving health care qu ality for patients.

    Mr. JEFFORDS. Mr. President, I want to begin by commending Senator NICKLES and all of the members who participated in putting the legislation together. I think it is solid legislation that will result in a greatly improved health care sy stem for Americans, and I am proud to be a co-sponsor of the ``Patients' Bill of Rights Plus.''

   As Chairman of the Committee on Health, Education, Labor, and Pensions, with its jurisdiction of private health insurance and public health programs, I anticipate that the Committee will have an active health care ag enda during the 106th Congress. In fact, on January 20th, the Committee held a hearing on health plan information requirements and internal and external appeals rights. And, this hearing builds on the foundation of fourteen related hearings that my Committee held during the 105th Congress.

   People need to know what their plan will cover and how they will get their health care. T he ``Patients' Bill of Rights Plus'' requires full information disclosure by an employer about the health plans he or she offers to employees. Patients also need to know how adverse decisions by the plan can be appealed, both internally and externally, to an independent medical reviewer.

   The limited set of standards under the Employee Retirement and Income Security Act (ERISA) may have worked well for the simple payment of health insurance claims under the fee-for-service system in 1974. Today, however, our system is much more complex, and there are many types of decisions being made--from routine reimbursements to pre-authorizations for hospital stays. And it is in the context of these changes, particularly the evolution of managed ca re, t hat ERISA needs to be amended in order to give participants and beneficiaries the right to appeal adverse coverage or medical necessity decisions to an independent medical expert.

   The provision of our bill giving consumers a new right of an external grievance and appeals process is one of which I am particularly proud, since it is the cornerstone of S. 1712, the Health Care QU EST Act, which I introduced with Senator LIEBERMAN during the last Congress. Under the ``Patients' Bill of Rights Plus,'' enrollees will get timely decisions about what will be covered. Furthermore, if an individual disagrees with the plan's decision, that individual may appeal the decision to an independent, external reviewer. The reviewer's decision will be binding on the health plan. However, the patient maintains his or her current rights to go to court.

   As the Health and Education Committee works on health care qu ality legislation, I will keep in mind three goals. First, to give families the protections they want and need. Second, to ensure that medical decisions are made by physicians in consultation with their patients. And, finally, to keep the cost of this legislation low so that it displaces no one from getting health care co verage.

   Our goal is to give Americans the protections they want and need in a package that they can afford and that we can enact. This is why I hope the ``Patients' Bill of Rights Plus'' we have introduced today will be enacted and signed into law by the President.

    Mr. CRAIG. Mr. President, today, Senate Republicans are responding to America's number one health care co ncern: the high cost of health insurance and medical care. B y granting all Americans access to tax-free medical savings accounts; by allowing self-employed Americans to deduct 100 percent of the cost of their health insurance premiums; and by allowing workers with flexible savings accounts to keep some of the money in those accounts, our ``Patients' Bill of Rights--Plus'' will tear down the barriers that government has put in the way of affordable health coverage and care. < p>   Our proposal stands in stark contrast to those offered by others in Congress. With millions of Americans unable to afford insurance because of the unfairness of the federal tax code, some members of Congress want to force consumers to buy government-prescribed benefits--including many that are giveaways to special interests--even if it causes millions more to lose their health coverage.

   While other so-called ``patients' rights'' bills contain nothing but expensive mandates, hidden taxes and costly lawsuits, our bill will deliver quality health insurance to millions of Americans. Our bill will make a down payment on serious health care re form th at puts patients first--not doctors, not lawyers, not insurance companies, and certainly not government bureaucrats.

   Rather than support a patients' bill of rights minus access, I urge my colleagues to take a step forward by making health insurance accessible instead of taking a step backward by making it more expensive.

    Mr. BURNS. Mr. President, I am pleased to support and co-sponsor patient protection legislation. There is noting more important than protecting the patient-doctor relationship and guaranteeing our citizens the right to choose their own doctor. It is important to make sure patients have the information they need to make decisions about their health care an d make sure doctors, not accountants or lawyers, decide which medical services are needed.

   Under Senator NICKLES' Patients' Bill of Rights Act, no health plan will be beyond the scope of federal or state patient safeguards. The bill will expand access to doctors, incuding guaranteed access to obstetrical and gynecological care an d pediatric care, a nd require managed ca re pl ans to offer patients the option to receive care ou tside a plan's network of doctors.

   In addition, health plans would have to provide patients with information on covered services, cost-sharing requirements, payment restrictions for services from out-of-network providers, rules for out-of-area coverage, preauthorization requirements and procedures, and rules for grievence and appeals filings. Health plans would be required to have both an internal appeal and external third-party review if coverage for any service is denied. Plans would also be required to safeguard patients' medical information or face civil penalties.

   The Patients' Bill of Rights Act will also make it easier for many Americans to afford health care. O ver 3 million self-employed individuals and their families will benefit from increasing the tax deductibility of health insurance to 100 percent, the same deduction most companies take for their employees. This bill also gives every American the right to have medical savings accounts (MSAs) and puts MSAs on an equal tax treatment footing with standard health care in surance. These flexible savings plans allow you to save money for health expenses tax-free as long as you have a high-deductible health insurance plan. MSAs are currently only available for employees in companies with 50 or fewer employees.

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