October 23, 1997
Advisory Panel to Recommend Broad Range of Patient Rights
By ROBERT PEAR
WASHINGTON -- A presidential advisory commission decided on Wednesday to recommend a
wide range of new rights for patients, including the right to appeal denials of care or
coverage by insurance companies and health maintenance organizations.
The 34-member panel, which includes top executives of managed-care companies as well as
doctors and consumer advocates, said that patients should be able to obtain an
"external review" of decisions that deny payment for services.
Many health plans now have their own procedures to deal with grievances and complaints.
The commission said that all patients should also have the option of appealing to an
independent outside authority, as Medicare beneficiaries do.
The panel also said that health plans, doctors and hospitals should be required to
disclose substantial amounts of new information and data that could help patients assess
the quality and experience of health care providers.
For example, it said, consumers should, on request, be able to find out how often a
doctor has performed a particular procedure and how often the treatment was successful. In
addition, it said, patients should be able to find out if their doctors have been sued for
malpractice, how the doctors are paid and whether the doctors receive bonuses or other
financial incentives.
Consumer advocates and some members of Congress say that such financial rewards may
encourage doctors to control costs by withholding care that patients need.
Kathleen Sebelius, the insurance commissioner of Kansas, a member of the commission,
said, "These proposals give consumers the tools with which to empower
themselves."
Another panel member, Stephen Wiggins, founder and chairman of Oxford Health Plans,
said: "Under these proposals, a urologist will have to disclose what percentage of
his patients are incontinent or impotent after he does surgery. This type of information
can produce a revolution in the health care system. Most patients have no idea if they are
the first person or the 50th person to have surgery performed by a particular
physician."
These and other proposals were endorsed by the commission as part of a "bill of
rights" for health care consumers. They come as Congress is considering numerous
bills to regulate health plans and health insurance companies.
President Clinton is expected to endorse the panel's recommendations, adding momentum
to the efforts on Capitol Hill. But the commission does not say how the new rights should
be enforced. It lists several alternatives, including voluntary actions by health plans
and new federal and state laws and regulations. Wherever possible, it said, the
recommendations should be carried out within three years.
Several members of the panel supported its proposals with reservations, saying that the
changes could increase costs for consumers, employers and insurers. In recent weeks,
several big managed-care companies have reported sagging profits, and experts on employee
benefits have predicted that premiums will rise substantially next year.
The panel, the Advisory Commission on Consumer Protection and Quality in the Health
Care Industry, will submit its recommendations on a bill of rights to the president late
next month, after a meeting here on Nov. 18 and 19. It will continue work through March
1998.
The commission, headed by Donna Shalala, the secretary of health and human services,
and Labor Secretary Alexis Herman, is working under rules that require virtual unanimity
for major recommendations. It has been unable to reach agreement on several thorny issues,
like patients' access to clinical trials of new treatments, lifetime limits on health
insurance coverage and the appointment of ombudsmen to help consumers navigate the health
care system.
The panel is still debating whether to recommend a ban on various types of
discrimination in the marketing of health insurance. Some panel members said they believed
that some health plans shunned low-income black and Hispanic neighborhoods or discouraged
enrollment of people with disabilities.
One commission member, Ronald Pollack, executive director of Families USA, a consumer
group, said the bill of rights would be incomplete without a ban on such discriminatory
practices. "It would be like adopting the Bill of Rights in the Constitution, but
excluding freedom of speech and freedom of religion," he said.
The panel's draft report does say that "all consumers are created equal." Its
recommendations would apply not only to people in Medicare, Medicaid and other government
programs, but also to people with private health insurance. In particular, the proposals
would apply to large employer-sponsored health plans that are not now subject to state
regulation.
The commission also approved chapters of a draft report making these points:
-- Consumers have a right to a choice of doctors within a health plan. Consumers should
be allowed to go outside the health plan, at no extra cost, if they need medical expertise
not available in the plan.
-- "Consumers with complex or serious medical conditions who require frequent
specialty care should have direct access to a qualified specialist of their choice within
a plan's network of providers." HMO's have often required patients to get permission
or referrals from family doctors before they visit specialists.
-- Health plans should be required to pay for emergency care in any situation that
"a prudent lay person" would regard as an emergency. HMO's sometimes refuse to
pay if, for example, chest pains are found to be a result of indigestion rather than a
heart attack.
-- Patients being treated for chronic illnesses or disabling conditions should be able
to continue seeing their medical specialists for at least two months if, for some reason,
the patients are forced to switch to another health plan. The purpose of this
recommendation is to make sure that the treatment is not disrupted.
-- Doctors should tell patients about "any factors" that could influence the
doctors' advice to patients. Such factors might include the doctors' investments in
hospitals, clinics, home health care agencies and diagnostic imaging centers.
In his 1993 health plan, Clinton asked Congress to create several government agencies
to help protect patients' rights and improve the quality of care. Shalala said that
Wednesday's recommendations were much more modest. "We are not redoing the Clinton
health care plan," she said.
L. Ben Lytle, president of Anthem Inc., a managed care company based in Indianapolis,
repeatedly told panel members that the proposals could increase the cost of health
insurance, so that some businesses would curtail coverage and more people would be
uninsured.
In its draft report, the commission said it tried to "balance the need for
stronger consumer rights with the need to keep coverage affordable." But it said,
"We recognize that, in some circumstances, these rights may create additional costs
for employers," insurers and consumers.
