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Your rights as patient up for debate in Washington

Eileen O'Connor

By Eileen O'Connor
CNN Medical Correspondent

July 9, 1999
Web posted at: 12:11 p.m. EDT (1611 GMT)

This news analysis was written for CNN Interactive.

In this story:

Costs vs. complaints

Defining rights

Mission impossible?

WASHINGTON (CNN) -- At water coolers, church socials and cocktail parties, people tell their tales of woe: horror stories about managed health care.

Next week, starting Monday, the Senate is set to debate a so-called "Patient Bill of Rights," a manifesto meant to empower the overwhelming majority of U.S. workers now enrolled in managed care plans.

The House's own health care reform bill is in committee, with the final version set to be drafted next week.

Advocates of a "Patient Bill of Rights" say it will level the playing field between patients and health insurance providers.

The debate affects more than those workers: Medicare already includes managed care options for seniors, and Medicare reform proposals now before Congress are set to include more HMO options. Already, 150 million people use some kind of managed care, and that number will only rise in years to come.

While both Republicans and Democrats agree that some kind of legislation to protect patients' rights is necessary, they vary widely on just how to do that while containing costs.

Few analysts in Washington believe this is the last we will hear of patient's rights. Democrats and Republicans agree on only a few areas on which to pass legislation. Also, analysts say, because this is such a hot-button issue, it's tempting for politicians to "play" it awhile in an attempt to score points for the 2000 campaigns.

Costs vs. complaints

Americans may have the best medical care available in the world, but millions of Americans have no access to it. In 1998, 43 million Americans were uninsured, according to government estimates.

Those numbers are related to the cost of insurance, which is related to the cost of health care itself. The price of medical treatments rose more quickly in the 1970s and 1980s than other sectors of the economy.

Advocates of a "Patient Bill of Rights" say it will level the playing field between patients and health insurance providers.

Economists blamed that inflation for damaging economic growth, by driving up the cost of insurance provided to employees in the private sector. Likewise in the public sector, high-priced medical care was blamed for driving up the costs to taxpayers for programs like Medicare and Medicaid.

The growth of managed care was the answer to Washington's failure to reform the system and cut costs.

Health maintenance organizations, or HMOs, offered companies and workers more affordable insurance, with lower out-of-pocket costs. To do that, they put certain limits on patients' ability to demand treatments they might not need. They also put limits on what hospitals and doctors could charge for certain services.

And that is when the patient complaints began.

Defining rights

Some 115 million Americans say they have had a problem or know someone who's had a problem with an HMO, according to Democratic lawmakers in Washington.

The complaints involve late payments, access to specialists, emergency room care and just who decides what care to provide a patient, among others.

Democratic lawmakers want to legislate patient protections for all Americans enrolled in managed care plans.

Republican lawmakers also want to introduce protections, but particularly for those enrolled in plans funded by the companies they work for; these are now exempt from some lawsuits and consumer protections under a law originally designed to protect pension plans. Republicans say other people are already protected by state laws, and that federal protection is unnecessary.

Both parties do agree on protections that would give patients more direct access to certain kinds of specialists, such as pediatricians or gynecologists. Both parties want to guarantee that health care plans would pay for emergency care if a so-called "layman" deemed it reasonable.

But Democratic lawmakers want the law to guarantee that a patient's doctor, not the patient's HMO, will ultimately decides what treatment is necessary.

"It doesn't do us any good to have the best medicine in the world if people can't get it," said Democratic Sen. John Edwards of North Carolina.

Health care ad
A recent managed care advertisement

Democrats also want to give patients the right to sue for punitive damages if they feel their HMO was responsible for injury resulting from its decisions.

Republican lawmakers favor outside, independent reviews, instead of lawyers, to handle complaints. They say the threat of lawsuits would raise costs, drive up premiums and make insurance unaffordable for companies to offer employees or for people to buy themselves.

The Republicans also argue for a written grievance process to help with determining treatment. They claim the Democrats' plan to give doctors control over treatment decisions reverts to the old system, where doctors sometimes ordered tests or treatments that were arguably unnecessary and insurance companies paid the bills regardless.

"Every increase, every 1 percent increase in premiums, drives about 300,000 more people to the ranks of the uninsured," according to Republican Sen. Bill Frist of Tennessee, also a physician.

But some supporters of the Democratic legislation claim Republicans want a bill that is unenforceable.

"I am amused when the insurance industry and the HMO industry shed 'crocodile tears' about the uninsured," said Ron Pollack, executive director of the Families USA Foundation, a nonprofit health care advocacy group. Democrats say the Congressional Budget Office has projected the Democratic version would cost pennies per day per patient.

"They [the industries] are using the uninsured as a shield to protect against very important legislation that protects the American public."

Mission impossible?

The managed care insurance industry claims it is listening to patients' complaints and that it has made strides in better billing procedures and better review processes.

Spokesmen say managed care is being charged with doing the impossible: cutting costs while offering whatever a patient wants at whatever price a doctor or hospital decides.

Spokesmen for the industry assert managed care is being unfairly treated and charged with doing the impossible: cutting costs while offering whatever a patient wants at whatever price a doctor or hospital decides.

"This [patient] bill [of rights idea] exacerbates one of the major problems that individual beneficiaries have, which is how to continue to have access to affordable health care," said Karen Ignani, president of the American Association of Health Plans, an industry lobbying group.

"We are in danger of legislating out of existence the very techniques that health plans use to keep costs affordable."

Since there is no clear consensus on how to solve these problems, analysts say, next week's debate may simply serve to heat up the talk at the water cooler as well.

y: CNN's Brooks Jackson finds with patients' rights bill, it pays to consider source of HMO numbers -- July 17, 1998

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