Key Patient Protections

H.R.358/S.6

(S. 1344)

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.

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except for some breast cancer patients.

Hold managed care plans accountable when their decisions to withhold or limitcare injure patients.

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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.

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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.

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NO

Require that health plans have an adequate number and variety of health care providers close to where consumers live and work.

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NO

Require that insurance companies pay for emergency services if a reasonable person would consider the situation an emergency.

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Unclear. The bill includes a good "prudent layperson" definition, but limits required coverage to those services necessary to "stabilize" (or, in some cases, to maintain stability of) 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 were rendered after the patient had been adequately stabilized.

Ensure that doctors and nurses can report quality problems without retaliation from HMOs, insurance companies, hospitals and others.

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NO

Prevent plans from financially rewarding health care professionals for limiting a patient’s care.

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NO

Give consumers access to an independent consumer assistance program to help them choose plans and get the services they need.

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NO

Allow doctors to prescribe prescription drugs not on the HMO’s predetermined list when needed.

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Prevent plans from denying access to clinical trials that may save people’s lives.

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except for some cancer trials.

Allow patients to appeal denials or limitations of care to an external, independent entity whenever their life or health is jeopardized.

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NO. 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.

Give women direct access to ob-gyn services from any qualified participating health care professional who provides such care.

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NO. The bill does not ensure access to participating health care professionals who are not physicians.