January 25, 1999

Honorable John Chafee
Honorable Bob Graham
Honorable Joseph Lieberman
Honorable Arlen Specter
Honorable Max Baucus
United States Senate
Washington, D.C. 20510

Dear Senators:

The American College of Physicians-American Society of Internal Medicine (ACP-ASIM), representing more than 110,000 physician-members who specialize in internal medicine, is pleased to comment on your bill. We believe your bill contains necessary patient protections, as well as provisions designed to foster quality improvement, and therefore has the potential to improve the quality of care patients receive. The College is particularly pleased that your proposal covers all Americans, rather than only those individuals who are insured by large employers under ERISA. We also appreciate that you have taken steps to address the concerns about making all health plans, including those exempt from state regulation under ERISA, accountable in a court of law for medical decisions that may result in death or injury to a patient. The College would like to continue to work with you to enact provisions that will provide patients with the best remedies possible.

The College supports the following specific provisions in your bill:

• requiring that health plans allow enrollees to appeal adverse coverage determinations to an independent physician;
• requiring that all enrollees in managed care plans be offered a point-of-service option, which will enable them to obtain care from physicians outside the health plan's network of participating health professionals;
• requiring a prudent layperson standard for emergency room coverage determinations;
• providing enrollees and prospective enrollees with the information they need to compare health plans, including quality indicators and measures;
• allowing patients to obtain care from the physicians within a health plan that are most qualified to treat them. (ACP-ASIM believes that the right to select the most qualified physician in a plan should not be limited to only a few designated specialties).
• requiring the Secretary to issue a report that establishes national goals for improvement of health care quality; and
• requiring health plans to maintain an ongoing continuous quality improvement program.

The proposal omits some important rights and protections, however. For example, the College has long argued that the medical liability system should be reformed by capping excessive non-economic damages.

In addition, although we have supported providing enrollees with appropriate quality measures, we are concerned that providing data on morbidity and mortality, without requiring that these data be risk adjusted, will mislead enrollees into believing that high morbidity and mortality means poor care. Risk adjustment is especially important when measuring individual physicians' performance, since individual physician practices vary widely and the most experienced physicians usually have the oldest, sickest patients.

Your bill also does not adequately address the need to ensure access to affordable health insurance coverage. Patient protections are meaningless if patients lack health insurance coverage. ACP-ASIM calls on the Congress to guarantee the most basic right of all Americans--the right to insurance coverage--by crafting legislative solutions that will reduce, with a goal of eventually eliminating, the growing numbers of uninsured citizens.

Thank you for your consideration of these important issues. The College would be happy to work with you as the debate on improving quality and protecting patients moves ahead.

Sincerely,

Harold C. Sox
President

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