The Norwood legislation also guarantees patients in a closed network the right of a point-of-service option, direct access to the care of obstetrician-gynecologists, and access to pediatricians. For patients with special conditions, the bill guarantees access to specialists. The bill also requires that plans cover emergency medical services without prior authorization, if a "prudent layperson" thought that such care was necessary. The bill allows a physician to prescribe drugs not on a plan formulary.
Under the legislation, plans must provide enrollees information on benefits, physician credentials, utilization management, and provider financial incentives and payment methods. The bill also bans so-called "gag rules" against provider discussions or treatment and coverage with patients.
Also in the bill: protections for doctors and other health workers who act as "whistleblowers" against health institutions. That is a crucial provision, Robert Weinman, president of the Union of American Physicians and Dentists, tells WebMD, since plans would have new legal exposure under the bill.
But the managed care battle in Washington is far from over. The focus now turns to the House-Senate conference, where the Norwood bill will square off -- without House GOP leadership support -- against the much more limited Senate-passed bill. The Republican-dominated Senate passed its bill this summer along strict party lines. It includes no right to sue, and many of its patient protections apply only to the 48 million Americans who are in self-funded plans exempt from state laws. By contrast, the Norwood bill applies to all Americans with health insurance.
Rep. James Greenwood (R, Pa.), a backer of the failed Coburn bill, predicted that a conference bill would be similar to the Coburn bill. "We've established a middle ground and the center will hold," he said. But Rep. Bill Thomas (R, Calif.) said, "You don't see many cross-breeds between Chihuahuas and Great Danes."
The conference negotiations will likely have political campaign overtones. An AMA lobbyist said that patient protection advocates may be able to sway some Republican senators who race tight re-election races.
But serious hurdles remain for enactment of legislation. For the conference, House Republicans have tied the patient protection bill to an "access" bill passed earlier in the week that establishes new health insurance tax breaks. The White House has threatened to veto that bill. The liberal-leaning consumers' group Families USA cautioned yesterday in a statement that linking the two bills gives "the insurance industry exactly what it wants -- a patients' bill of rights that will never be enacted into law."