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U.S. bans 'gag orders' on advice for HMO Medicare patients
December 7, 1996
Web posted at: 10:20 a.m. EST
WASHINGTON (CNN) -- The federal government has made it illegal for HMOs to limit what doctors tell Medicare patients about treatment options not covered by their conventional health plan.
The new policy was issued in letters sent by the Department of Health and Human Services to health maintenance organizations across the country, HHS Secretary Donna Shalala told CNN Saturday.
"We notified those that provied managed care for Medicare recipients that they cannot have a gag rule," Shalala said.
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In the letters, the government said a doctor caring for a Medicare patient "may not be limited in counseling or advising the beneficiary" about treatment options that may be appropriate for the patient's condition or disease.
"Most managed care companies want to give every piece of information," Shalala said,
and the idea of the new rule is to make sure it stays that way.
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In the letters, the government said a doctor caring for a Medicare patient "may not be limited in counseling or advising the beneficiary" about treatment options that may be appropriate for the patient's condition or disease.
Doctors say such "gag orders" interfere with their ethical and legal duties to inform patients about the benefits, risks and costs of various treatments.
But supporters argue gag clauses have helped HMOs keep costs down.
The Department of Health and Human Services said Medicare HMO patients were entitled to all benefits available in the standard Medicare program, which pays doctors a separate fee for each service. One of those benefits, the agency said, was advice from doctors on "medically necessary treatment options."
In its conclusion, the department said any contract that restricts doctors' abilities to advise and counsel a Medicare HMO patient was a violation of federal law. Federal health officials said they planned to issue a similar policy for HMO Medicaid patients.
Medicare finances health care for some 38 million elderly or disabled Americans. Nearly 5 million Medicare patients are in HMOs. An estimated 80,000 beneficiaries enroll in such plans each month.
Medicaid provides care for 37 million low-income people. More than 12 million of them are enrolled in HMO plans.
HMOs have been highly effective in controlling health costs by encouraging the use of selected doctors and hospitals, limiting access to medical specialists and curbing the use of costly tests and procedures, The New York Times reported Saturday.
Candace Schaller, a lawyer at the American Association of Health Plans, which represents HMOs, told the Times her group welcomed the decree because HMOs "support full, open communication between physicians and patients on clinical matters."
But Carol O'Brien, a lawyer at the American Medical Association, disagreed that most HMOs have been open.
"We have reviewed more than 200 contracts in the last two years, and virtually all of them had some kind of gag clause provision," she said. "In numerous cases, physicians have been disciplined or threatened with termination for discussing treatment options that were not covered by the plan."
Related sites:
Note: Pages will open in a new browser window- Health Care Financing Administration
- National Health Infomation Center
- Health Policy Page
- Facts on Medicare
- Medicare Info
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