Patients Bill of Rights:
Will It Happen, and Will It
Dinners cooking on the stove and
youre half watching the evening news where lots of serious-looking people in dark
suits debate health-care reform, throwing around terms such as medical
necessity and utilization review. Meanwhile, in the other room, your
toddler wails in pain with yet another ear infection, prompting your own internal debate:
Do you switch off the burner under the Hamburger Helper and take your sick kid to the
emergency room, or wait to see the pediatrician tomorrow so you dont get in trouble
with the health maintenance organization?
it or not, the talking heads on TV are actually trying to make your medical decision
easier. The patients' rights debate now raging in Congress is fueled by polls that say
people like you are fed up with the way managed care treats patients. You want to be able
to see the doctor when you need and know the health plan will pay.
Of course, given the intense politicking around this
issue, you may find it difficult to see your own life and problems reflected in all the
partisan bickering. What do you care how members of Congress use their votes on this
volatile issue in their campaign commercials? It doesn't make your baby feel any better.
Still, when the dust settles, you may find legislators
actually did something that affects you. The most likely provisions to make it through the
political meat grinder are likely to be fairly innocuous for instance, requiring an
outside, independent review of disputes between HMOs and their members. Some HMOs have
already begun offering third-party review voluntarily.
As for anything more substantial, both sides have
promised to nix their opponent's favorite provisions. For instance, business interests are
in the midst of an ad campaign to defeat a proposal that grants patients the right to sue
their health plans. Consumer advocates, complain that HMOs don't have to face the
consequences of their decisions because of ERISA, a federal law that shields them from
most lawsuits. But insurers argue that lawsuits would be counterproductive and would
simply raise insurance costs for everybody. "We don't think trial lawyers are the
sole guardians of quality of care in the health-care system," says John Murray,
director of public affairs for the American Association of Health Plans. Instead, Murray's
organization says external review of disputes by a third party should give patients all
the recourse they need.
At the same time, consumer advocates have found what
they call "poison-pill" provisions, such as allowing "medical
underwriting" the practice of charging higher rates to people more likely to
become sick that prevent them from supporting the proposal.
Judy Waxman, government affairs director of Families
USA, believes enough Republicans in the House support a more consumer-friendly bill that
it could pass, who have joined ranks with consumer groups against insurers and business
lobbyists. The House has to pass something. The questions will be what will they pass and
what happens in the Senate.
To muddy the waters even further, some of the consumer
rights proposed are limited to certain people. For instance, the legislation approved by
the Senate applies in large part only to the 48 million Americans who get health coverage
from larger companies that insure themselves, as opposed to employers that buy insurance
from a health plan. And the vast majority of these people aren't even in HMOs, whose
restrictive practices have prompted the calls for reform; instead, this group favors
traditional fee-for-service plans, or PPOs.
Few are willing to hazard a guess as to whether the
House can pass meaningful legislation and then somehow make it match what the Senate has
done. Larry Levitt, who researches the health-care system for the Kaiser Family
Foundation, looks to the past when trying to predict the future. "The chances of
ending up with something are slim," Levitt says.
The bottom line: Don't get too excited about potential
changes in how your HMO operates. Even if Congress acts on this issue, the results are
likely to be so watered down that the new protections will affect you only in an unusual
situation, and there's a decent chance you won't fall into one of the special categories
of people who get protected. The best advice is to know your health plan's rules, know who
to bother when you don't get what you need, and be vocal when care is denied. And about
your kid's earache: Follow your instincts; dinner can wait.
Our Rights Return