The Medicare Patient Choice and Access Act of 1997 is needed to protect the health care needs of senior citizens, said Representative Sherrod Brown (D-Ohio) at APA's Federal Legislative Institute on Capitol Hill last month. He and Representative Tom Coburn, M.D. (R-Okla.), introduced the bill, which APA supports, in January.

"Efforts to constrain costs should not interfere with the quality of health care," said Brown. "We believe this bill would guarantee senior citizens who rely on Medicare the right to choose their health care provider and assure the delivery of high-quality medical care."

Gag clauses that restrict physician-patient communication are prohibited under the bill. Specific topics that physicians should discuss with their patients are provider compensation practices, utilization review procedures, formulary medications, a plan's decision-making process regarding experimental procedures or treatments, a patient's physical or mental condition, and treatment options.

The bill requires plans to provide senior citizens a point-of-service option at the time of enrollment. Out-of-network services would be available for an additional cost, which should not be prohibitive, the bill states.

At press time, the proposed legislation had 74 cosponsors and was awaiting action in the House Commerce Committee. Coburn is a member of that committee.

Health plans with closed panels would have to guarantee enrollees "timely and appropriate access" to primary and specialty health care providers.

"The patient's first point of contact in a health care plan would be encouraged to make all appropriate medical referrals," the bill states.

Specialty care must be available for as long as it is medically necessary and should not be subject to arbitrary time limits, the bill states.

Direct or indirect financial incentives to providers to limit care or referrals to specialists would be prohibited. "Direct access to specialty care is essential for patients in emergency and nonemergency situations and for patients with chronic and temporary conditions."

The bill also requires health care plans to have a timely appeals process so that enrollees' complaints can be resolved within 30 days of the filing date.

The process would include providing enrollees written notification of the reasons for the denial, a description of the complaint process, and how to obtain supporting evidence for the hearing.

The bill states that an appeals board must be composed of physicians, providers with expertise relevant to a patient's diagnosis and treatment, enrollees, and consumers who are not enrollees.

Medicare beneficiaries are also entitled to know their rights and any plan restrictions, stated Brown.

At the time of enrollment and then annually, beneficiaries must receive a description of plan benefits, payment restrictions for services, coverage for emergency services and services provided outside of a local area, coverage for out-of-network services, and rights related to appeals.

Moreover, health care plans must provide enrollees with a comprehensive checklist of information to facilitate comparison of plans.

A checklist must address plan premiums, in-network provider qualifications and availability, the number of individuals enrolling and disenrolling, procedures to control costs and services and assure quality, and enrollees' rights and responsibilities.

(Psychiatric News, May 16, 1997)