|The majority of patients and providers are
enrolled in managed care or health maintenance organizations
(HMOs). Approximately 67 percent of privately insured
Americans are now covered by HMOs and the number of Medicaid
and Medicare beneficiaries enrolled in HMOs continues to
increase. As these numbers have increased, the need for
patient protections in managed care has become increasingly
apparent. There is mounting evidence that quality care is
being compromised by cost containment.
Many states have recognized the need to protect patients
and have passed various initiatives. However, any changes in
state regulation only affect those people who are covered by
insurance plans regulated by the states. Approximately 60
percent of the insured population are covered under
self-funded plans, which fall under the Employee Retirement
Income Security Act (ERISA). ERISA plans are not subject to
state regulations. In order for all patients to be protected,
federal action is necessary.
Any patient protection reform should, at a minimum,
- Point-of-service option -- allow patients
to see providers out of network if they agree to pay a
reasonable co-payment. A choice between two closed-panel
plans does not constitute a point-of-service option.
- Access -- patients have access to a
sufficient number of providers to receive the benefits
offered by a plan and access to specialists within and
outside a plan.
- Gag-rule -- plans cannot prevent providers
from discussing various treatment options with their
- Accountability -- patients should be able
to hold their health plan accountable for the decisions of
medical necessity that the plan makes. This includes a
strong internal and external review process that is binding
on the plan.
These four provisions were included in the House-passed
Bipartisan Consensus Managed Care Improvement Act of 1999
(H.R. 2723), introduced by Representatives Charlie Norwood
(R-GA) and John Dingell (D-MI). APTA strongly supports H.R.
2723 and opposed the Senate's weaker version of patient
protections, S. 1344, the Patients' Bill of Rights Plus Act.
Additionally, APTA urges the use of the term "health care
professional" throughout any patient protection legislation.
We are concerned that in many bills there is an inconsistency
in terminology by not using the term health care professional
throughout the bill. Patients receive services from a range of
health care professionals, not just physicians.
If the term "physician" is used, it will have an adverse
affect on patient choice and access. This distinction is also
important in any internal and external panels that are
established in legislation. The use of the term "physician"
can have the effect of inadvertently, and inappropriately,
excluding non-physician health care providers, such as
physical therapists, from such panels. This, in effect, will
reduce the access and choice of the patients who want to
receive services from the full range of health providers
qualified to provide services under state law.
APTA urges your support of these key provisions as
contained in H.R. 2723. These standards are not a radical
reform of our health care system. They are a set of minimum
safeguards needed to protect all Americans. The time to act is
For more information, please contact Kristen Nelson,
Assistant Director of Federal Affairs, at (703) 706-3165.