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APTA Supports "Bipartisan Patient Protection Act of 2001" Legislation
Patient Protections in Managed Care
APTA Applauds Patient Protection Bill (posted 10/8/99)

    
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Patient Protections in Managed Care

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, include:

  • 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 patients.
  • 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 NOW!

For more information, please contact Kristen Nelson, Assistant Director of Federal Affairs, at (703) 706-3165.  


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