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.

Health 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.

Instead of 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 excluded.

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.