In an otherwise lackluster re-election year, Congress is turning up the heat on America's favorite villains: managed-care companies.
In a flurry of headline-grabbing activity before the August recess, both Republicans and Democrats pushed healthcare reform bills that would expand patients' rights and rein in managed-care organizations.
The American Medical Association has been aggressively lobbying for passage of the Democratic Patients' Bill of Rights, and last month declared July 16 official "Patients' Bill of Rights Day." On the previous day, President Clinton visited the association's Washington offices to hear managed-care horror stories.
Both parties' reform proposals offer patients increased access to specialists and physicians outside HMO networks, and both eliminated gag clauses. But the Democratic Patients' Bill of Rights also would permit patients to sue HMOs for medical malpractice, whereas the Republican plan would not.
Currently, under the federal Employee Retirement Income Security Act of 1974, self-insured health plans are exempt from state regulation, including medical malpractice laws. Patients who want to challenge HMOs' denial-of-care decisions have no recourse other than internal complaint procedures. ERISA has come under attack in recent years from attorneys and consumer advocates who charge that the law was written before the advent of managed care and was not intended to shield health plans from legal action.
A report last month by the General Accounting Office found "ERISA effectively limits the remedies available when employees of private-sector firms claim to have been harmed by plans' decision to deny coverage of a particular service."
Republicans say their plan would expedite the complaint and appeals process. It would give patients access to immediate decisions about what is covered and require plans to allow an independent doctor to decide on the medical necessity of requested services that had been turned down by internal review.
Not surprisingly, the American Association of Health Plans is opposed to legislation that would allow patients to sue HMOs. In response to the Democrats' plan, the AAHP released a statement declaring it would be an "expansion of an already flawed medical malpractice system (that) would lead to higher healthcare costs for consumers with no proven improvement in the quality of healthcare."
AMA Chairman Randolph Smoak, M.D., counters: "When a physician makes a decision, that physician is held strictly accountable. When a health plan makes a medical decision, it should be held just as accountable."