Arguments in Favor of
Patient Access and Health Care Competition Language
"A health benefit plan or health insurance issuer,
consistent with its needs to maintain standards, control costs and
utilize health care professionals that meet the needs of the plan's
enrollees, shall not condition participation or payment to a health
care professional who is acting within the scope of the health care
professional's license or certification under applicable state law,
solely on such certification or license. Nothing in this section
shall be construed as an 'any willing provider' requirement."
On March 17, 1999, Muse and Associate, a well-respected
Washington actuarial firm, completed a study on the health care
premium impact of the Patient Access and Health Care Competition
language. The Muse study found that this provision would have no
negative effect on premiums for those enrolled in managed care
plans. In fact, the study found that administrative savings could be
achieved with respect to managed care plans with contracts that
serve both Medicare beneficiaries and the private marketplace,
through uniform patient access provisions and quality standards.
Hence, the overall affect of this provision could theoretically be
to reduce premiums.
This language would create a "level
playing field", allowing all health providers, acting within their
scope of practice, to compete in managed care plans. This
competition would promote efficiency within the health care
marketplace while increasing patient satisfaction.
Care Competition language will encourage managed care plans to make
greater use of their pool of health care professionals which are
presently available, giving patients a greater choice of providers.
Consumers would likely enjoy lower health care costs because
there would be a greater supply of providers, thereby driving-down
costs, particularly since many non-MD providers maintain the same
quality as MDs while providing services for less.
denying patient care due to an inadequate supply of some services,
at least make it clear to both managed care plans and patients that
as long as the services are to be provided, health professionals
acting within the scope of their licensure should not be arbitrarily
This language is not "any willing provider." It
does not require health plans to "take all comers." It simply
prohibits a managed care plan from excluding health care
professionals' entry into the plan solely on the basis of their
license or certification.
As Congress looks to increase
patients' access to care, while keeping cost at a minimum, many
members of Congress, patients, and provider groups will become
justifiably concerned if this consumer protection is not included in
the final managed care reform bill that is signed into law.