Statement of Douglas P. Zipes, M.D., President, American College of Cardiology,
and Professor of Medicine, Indiana University School of Medicine,
on behalf of the Patient Access Coalition

Testimony Before the Subcommittee on Health
of the House Committee on Ways and Means

Hearing on Patient Protections in Managed Care

April 24, 2001

The Coalition was formed in 1993 in the context of congressional debate over comprehensive health system reform to ensure that any resulting legislation would contain the guarantee that every patient would be able to choose the kind of medical treatments and services they needed. The Coalition was the first national organization of patient and provider groups to call for federal patient protection legislation. And for nearly eight years, we have stood united in our concern that the focus of health care in this country must be on patients and the quality of their medical care.

Throughout the years, the Coalition has not deviated from its strongly held belief that all patients in managed care plans must have health care choice and access, and that health plans must be held accountable. This is why we believe that all patients should be guaranteed basic protections from health plan practices that could negatively affect medical outcomes.

Choice

Two of the Coalition's chief principles are patient access to a point-of-service option and timely access to specialty care. Patients must be allowed treatment by the health care provider of their choice. A point-of-service option at the time of enrollment is the ultimate patient protection against poorly managed health care plans. This choice could be offered with no additional cost to the employer.

Direct access to specialty care is essential for patients in both emergency and non-emergency situations, for patients with chronic and temporary conditions, as well as those with unexpected acute care episodes. Specialty care must be available for the full duration of the occurrence and must not be limited by the number of visits. Furthermore, any routine costs incurred for items and services furnished in connection with participation in clinical trials must be covered by the health plan.

Access

In addition to ensuring choice and access, barriers that impede access and put patients at risk must be eliminated. Any legislation must include a ban on health plan financial incentives and gag clauses, as well as full disclosure of health plan information to patients.

I want to take a moment to elaborate on what we mean by prohibiting financial incentives. Financial incentives should not interfere with medical judgement. For instance, health plans must be prohibited from establishing arrangements where the gatekeeper has a financial incentive not to refer patients. We need to protect patients from under-referral for financial gain.

Accountability

The patient protections of access and choice that I have outlined have limited value unless the managed care plan is held accountable for its actions. One of the most consistent complaints against managed care plans is that, when the providers or patients appeal a decision, health plans are slow to act. Because decisions about patients' care can be a matter of life and death, managed care plan foot-dragging can have profound consequences.

To protect patients and give them a meaningful right to appeal, sound and timely internal and external appeals processes are critical. In the case of external appeals, the review must be de novo and genuinely independent, and the review panel's decision must be binding on the health plan. The external reviewers must have clinical expertise in the area in which the review is being conducted, and the findings of the external reviewers must not be constrained by the health plan's definition of medical necessity. Decisions on urgent/emergency cases must be made within an expedited time period. These enhanced internal and external review processes will assist consumers in obtaining access to appropriate services in a timely fashion, thus maximizing the likelihood of positive health outcomes.

These principles, if incorporated into federal legislation in a meaningful way, will go a long way toward protecting patients in managed care plans and ensuring that patients get the care they pay for and deserve.

Most importantly and without exception, these protections must be guaranteed to all patients in managed care plans to the extent that they are not already enforced through stronger state laws.

In 1996, the Coalition's efforts, working with this committee, led to the only set of federal patient protections ever to be signed into law. Those patient protections were enacted as part of the Balanced Budget Act of 1997 and apply to Medicare and Medicaid beneficiaries enrolled in managed care plans. It has been four years since Medicare and Medicaid beneficiaries were guaranteed these basic and fundamental protections.

We are aware that the debate on the issue of accountability has centered on the patient's ability to bring suit against health plans. This debate has been complicated by the many variables associated with liability. Because of the divisiveness of this issue, and the various positions held by individual organizations within the Coalition, we have not taken a position on liability. However, we strongly believe it is time for Congress to finish its work and pass legislation this year to make basic patient protections apply to all managed care enrollees.

Madam Chairwoman, the Patient Access Coalition firmly believes that enactment of its patient protection principles will ensure that patients have real choice and timely access to quality health care. Our approach is straightforward and comprehensive and places nonintrusive, reasonable requirements on the health insurance industry. We look forward to your leadership and want to work with you to see that enactment of these patient protections occurs this year.

Madam Chairwoman, I thank you for allowing me the opportunity to speak before you and your subcommittee.

[The attachments are being retained in the Committee files.]