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APA ONLINE Practice
Enact Patient Protections in Health Insurance Reform


March 6, 2000
Government Relations
Practice Directorate
For more information: Pracgovt@apa.org


Managed care reform conferees should address these essential patient protections to ensure quality care:

  • Health Plan Legal Accountability. Conferees should adopt the House-passed provision, as contained in the Norwood/Dingell bill, H.R. 2990. The House accountability provision affords injured patients a right of recourse, while protecting employers from inappropriate actions. According to CBO, the Norwood/Dingell provision will increase insurance premiums by only 1% (CBO, 2-10-00), which is a mere penny per person per day.

A legal "loophole" in ERISA denies patients, injured by the negligent health care decisions of their ERISA-regulated managed health plans, the right to hold these plans legally accountable for their decisions. This loophole has allowed negligent managed health plans to avoid accountability and has removed an important incentive for their provision of high quality health care.

Compromise is possible to further protect employers from frivolous claims. A strong internal and external appeals process, punitive damages limitations, and reasonable judicial procedural limitations could be included to prevent frivolous actions. Compromise, however, should not be reached at patient expense:

    • A "substantial harm" standard that requires a "physical injury" should not be included, as this standard bars from any legal recourse patients with mental health diagnoses, who are injured by the negligent denial or delivery of their treatment.

    • A noneconomic damages cap should not be included since children and stay-at-home parents, who have no or very low economic damages, may not be afforded adequate relief for potentially devastating injuries.

  • Physician-only References. The Senate-passed bill, S. 1344, permits only physicians to fully participate in internal and external review of services to the detriment of patients under the care of other health care professionals. Only physicians may advocate on behalf of their patients during review. Only physicians may review care, even when other professionals are qualified to review services. The Conferees should accept the House provisions with an amendment to ensure that psychologists may review the services that they are qualified to provide.

  • Patient Choice of Provider (Point-of-Service). Conferees should include the "point of service" provision contained in both the House and Senate bills. Sponsors of health plans that offer services only through a closed network of providers should offer also a separate POS plan that allows patients access to out-of-network services.

A POS plan option permits patients to continue current relationships with providers whom they rely upon and trust. It is a quality check for managed health plans by permitting dissatisfied patients to seek care from providers and specialists outside networks of care. A POS option is also particularly important for persons seeking and receiving mental health and substance abuse services for reasons of trust, confidentiality and treatment success.

  • Patient Access to a Range of Providers. Conferees should include the "provider nondiscrimination" provision contained in both the House and Senate bills. Providers should be able to compete to deliver services to patients. Managed health plans, therefore, should not exclude a type of provider from fair participation in their networks based solely on licensure or certification.

Patients in rural and frontier areas would benefit particularly from this provision, gaining greater access to services near their homes, where nonphysician providers are more prevalent than medical specialists and qualified under State law to provide many of the same services.





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