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A broad patient protection bill with more than 200 cosponsors in Congress mandates a point-of-service option in managed care plans and equal pay for physicians inside and outside of health plan networks, and amends ERISA's preemption of state malpractice laws.
The Patient Access to Responsible Care Act, introduced by Representative Charles Norwood (R-Ga.) in December, "appears to be the best patient protection legislation in Congress. We are working very hard with the AMA to try to get this legislation passed," according to Ronald Shellow, M.D., chair of APA's Joint Commission on Government Relations.
"We like this legislation because it addresses the unfair ERISA preemption of state malpractice laws, which allows many managed care organizations not to accept responsibility for their decisions," Shellow told Psychiatric News.
Patients must have the final say in choosing their doctors and health plans, and managed care plans must be responsible for injury and death caused by medical decisions that deny promised and medically necessary care, said Norwood in a February Roll Call article.
Norwood is committed to keeping the controversial Employee Retirement Income Security Act (ERISA) provision in his bill that breaks down the ERISA shield to allow injured persons to sue plans for damages under state malpractice law.
"Health insurance is the only industry in this country that has a Congressionally mandated shield against any responsibility for [its] actions," commented Norwood, a dentist who stopped practicing when he ran for Congress.
"That is precisely why we have problems with denied emergency room care, drive-by mastectomies, and heart attack victims being sent home to take an aspirin and call their doctor in the morning. The bad plans know that if the worst happens, and the patient is injured or dies, their company can't be touched. Change that, and we change the entire system," said Norwood in the press statement.
Cost estimates released by Norwood's office last month show that patients can be protected legally with only a small increase in insurance premiums. The average premium cost a month ranged from a high of $1.26 based on a Multinational Business Services study released last month to a low of $.32 based on a study by Muse and Associates released in January.
However, the leadership of both parties and President Clinton are reluctant to take on the ERISA preemption. The managed care lobby opposes, contending that such a preemption would bankrupt the health insurance industry, according to Norwood's press statement.
The Congressman is also committed to patient choice. His bill requires closed networks to offer a point-of-service option with "fair and reasonable" premiums set by the National Association of Insurance Commissioners. Payment for out-of-network care must be equal to rates for in-network care with no balance-billing limits for the point-of-service option.
Norwood's bill also mandates that utilization review standards be developed with health professionals. Reviewers must be
"licensed, accredited, or certified health professionals. For specialty care, reviewers must be a health professional who is qualified through equivalent specialized training and experience."
Norwood observed that his mandated ERISA preemption, point-of-service option, and utilization review standards are not included in the Patients' Bill of Rights recommended by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry.
Nonetheless, there are similarities between the Bill of Rights and Norwood's bill: They both call for external appeals mechanisms, visits to emergency rooms without first having the insurance company's permission, prohibitions on gag clauses, medically necessary specialist care, detailed explanations of health benefits, and confidentiality of patient medical records.