How the House and Senate Leadership Proposals
Measure Up on Some Key Patient Protections

updated 3/99

Key Patient Protections	Patients' Bill of Rights Act (S. 6/ H.R. 358)	Bilirakis/Hastert Bill H.R. 448	Senate Leadership Bill S. 326
Ensure that treatment decisions -- such as how long patients can stay in the hospital after surgery -- are made by a patient's doctor, not an insurance company.		NO	NO
Hold managed care plans accountable when their decisions to withhold or limit care injure patients.		NO	NO
Ensure that patients in the middle of treatment can continue to see the same health care provider if their provider leaves the plan or their employer changes plans.		NO	NO. Continuity is not ensured when employers switch plans. When a provider leaves a plan, continuity is available only when the patient is pregnant, institutionalized, or terminally ill.
Allow patients to see an outside specialist at no additional cost whenever the specialists in their plan can't meet their needs.		NO	NO
Require that health plans have an adequate number and variety of health care providers close to where consumers live and work.		NO	NO
Require that insurance companies pay for emergency services if a reasonable person would consider the situation an emergency.		NO. The prudent layperson definition does not include "severe pain" as a symptom that justifies seeking emergency care. Plans can charge patients extra if they go to a non-network provider.	Unclear. The bill includes a good "prudent layperson" definition, but limits required coverage to those services neccessary to "stabilize" the patient. Patients could be left with bills for services rendered by emergency room personnel if the plan concludes, after the fact, that those services had been rendered after the patient had been stabilized.
Ensure that doctors and nurses can report quality problems without retaliation from HMOs, insurance companies, hospitals and others.		NO	NO
Prevent plans from financially rewarding health care professionals for limiting a patient's care.		NO	NO
Give consumers access to an independent consumer assistance program to help them choose plans and get the services they need.		NO	NO
Allow doctors to prescribe prescription drugs that are not on the HMO's predetermined list when needed.		NO
Prevent plans from denying access to clinical trials that may save people's lives.		NO	NO
Allow patients to appeal denials or limitations of care to an external, independent entity whenever their life or health is jeopardized.		NO.1	NO.2
Give women direct access to ob-gyn services, without limitations (such as limits on the # of visits) that impede access to services.		NO. Direct access to physicians is ensured, but not direct access to other types of health care professionals that are in the plan's network.	NO. The bill does not clearly ensure access to participating health care professionals who are not physicians.

Notes:

¹The appeal provisions in this bill are flawed in many ways, including: 1) The "external" review is merely one step in the plan's internal reconsideration of its own denial and is not binding on the plan. 2) The independent medical expert who reviews the coverage decision is not authorized to make a scientifically based objective determination of medical necessity or appropriateness; rather, the expert is authorized only to determine whether the plan's denial "was in accordance with the terms of the plan." 3) There is no provision for expedited reconsideration in urgent or emergency situations. 4) Plans may impose a filing fee (up to $100) that may prevent patients from even initiating a reconsideration.

²NO. The bill does not allow all patients whose life or health is in jeopardy to seek an external appeal. It only provides for an external appeal in limited circumstances: when the plan denied the care because the plan decided the care was not "medically necessary and appropriate" (or was experimental or investigational). Plans can exercise medical judgment and deny care or access to specialists in situations that may not fall squarely within the "medically necessary and appropriate" framework. In addition, the bill allows plans themselves to define the term "medically necessary and appropriate", no matter how inconsistent with best medical practice that definition may be, and the plan's definition governs the circumstances under which external review is permitted. A plan does not have to allow an external review when care fails to meet the plan's definition of what constitutes medically necessary care -- even if the care is medically necessary by a more objective measure.

Click here for more information on the Patients' Bill of Rights Act (S. 6/H.R. 358).