Patients' Bill of Rights Passes Senate— Support Needed for Strong Managed Care Bill in the House

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July 19, 2001—The Bipartisan Patient Protection Act of 2001 (S. 1052) sponsored by Senators Edward Kennedy (D-MA), John Edwards (D-NC) and John McCain (R-AZ) was passed by the Senate on June 29, 2001.

The Act comes after a long line of lawmakers' attempts at making managed health care safe for patients. Although in the last Congress, House Democrats passed a bipartisan bill that would have made HMO's accountable for their actions, Senate Republicans passed a weaker bill, and the two bills could not be reconciled in conference.

The passage of S. 1052 marks a new opportunity for Congress to guarantee patients a uniform federal floor of patient protections. The Act:

• Applies comprehensive protections to all Americans in health plans. Under the Act, states can not enact weaker standards; they may only adopt standards that are stronger or are substantially equivalent to those called for by S. 1052.
• Allows for timely, independent appeals processes for patients who have had claims denied. In addition, when patients have emergencies, claim review can be expedited.
• Adheres to the standard set out in the landmark Supreme Court case Pigram v. Herdrich. Under Pigram, cases concerning medical judgment can be heard in state court, but cases involving plan administration must be heard in federal court, so as to ensure that insurers can administrate their plans uniformly.
• Requires plans to allow patients access to specialists, even if they have to go out of the plan's provider network. If the plan has failed to meet the patient's needs, they must provide patients this access at no greater cost than if the benefit were obtained from the plan's in-network providers.
• Applies the "prudent layperson" standard to review of ER visits, meaning that if a patient reasonably believes that she needs emergency care, she can go to any emergency room, regardless of whether it is in network, without prior plan authorization.
• Allows women to list their OB/GYNs as their primary care providers, and members to make pediatricians the primary care providers for their children.
• Protects continuity of care for patients who are in the middle of a course of treatment for a chronic or disabling illness by requiring a transitional period during which patients can continue working with their providers if they are forced to change plans or their providers leave the network.
• Assures that plans will not prevent doctors and nurses from discussing all treatment options with their patients. It also prohibits incentive arrangements that make doctors limit care in order to avoid financial pressure.

Managed Care Debate Moves to the House

Senate passage of the Bipartisan Patient Protection Act was a victory for health care consumers; however, support is still needed to ensure that its counterpart (H.R. 526) sponsored by Representatives Greg Ganske (R-IA) and John Dingell (D-MI) passes in the House.

Recently, Representative Ernie Fletcher (R-KY) introduced a watered down version of a managed care protection bill, (H.R. 2563) that has support from the House leadership and the White House. Please note—this is a new bill number. Formerly, H.R. 2563 was known as H.R. 2315. Representative Fletcher's bill pays lip service to ensuring patient protections, but in reality provides no strong guarantees that protections will be enforced. Where H.R. 526 allows patients to sue in state court for death or injury caused by medically reviewable decisions, the Fletcher bill only allows access to state courts when the plan has disregarded the findings of an independent review entity. In all other cases, ERISA preemption maintains HMOs' unfair advantage by ensuring that patients have no recourse to state courts-even in the face of capricious denials of benefits.

Furthermore, H.R. 2563 fails to guarantee meaningful patient protections to all Americans enrolled in health plans. Under the Fletcher bill, no patients enrolled in federal health programs would be entitled to protections. And the protections afforded private enrollees would be substantially weakened, not only by ERISA preemption, but also by a provision in H.R. 2563 that arbitrarily caps punitive damages at $500,000-even in the most grievous cases of HMO misconduct. Additionally, unlike the "real" managed care bill (Ganske-Dingell, H.R. 526), the Fletcher bill contains no bar on the inappropriate incentive plans that pressure providers to offer fewer services.

What You Can Do

Call Congress TOLL FREE today at 1-877-703-9491 to get connected to your Representative to say VOTE NO on the Rep. Fletcher bill and to VOTE YES on the Reps. Ganske and Dingell House bill (now known as HR 2563).