Bipartisan House Passes Strong HMO Patient Protections

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Oct. 7, 1999 (Washington) -- Consumers and physicians won a major round in the battle over managed care patient protections, as the House Thursday overwhelmingly approved a bipartisan measure that would give patients a range of new rights, including the ability to sue health plans.

The 275-151 vote for the legislation introduced by Reps. Charlie Norwood (R, Ga.) and John Dingell (D, Mich.) also marked a major defeat for GOP leaders, who had pushed a significantly more limited alternative. Sixty-eight Republicans voted for the Norwood bill.

Earlier in the day, Democrats lost only two of their members while picking up 29 Republicans to defeat a substitute bill endorsed by the GOP leadership. Reps. Tom Coburn, MD (R, Okla.), and John Shadegg (R, Ariz.) wrote that measure, which failed 238-193.

Another Republican bill, from Rep. John Boehner (Ohio), included no right-to-sue provision and was torpedoed 284-145. Still another GOP alternative, from Reps. Amo Houghton (N.Y.) and Lindsey Graham (S.C.), lost 269-160.

As its centerpiece, the Norwood bill grants patients the right to sue their health insurance companies in state courts. It also requires that HMOs establish external independent medical review boards for disputed care issues. Plans would pay the costs of reviews, and panel decisions would be binding. Under the bill, a patient could still sue an HMO if a board ruled against them, but that suit would go to federal court.

The close to 300 health provider and patient groups that backed the Norwood plan were jubilant. In a statement, the president of the American Medical Association (AMA), Thomas Reardon, MD, called the vote a "colossal victory for patients."

The issue of patient rights in HMOs carries enormous emotional resonance, which lawmakers played on throughout the day's debate. Before his final floor speech for the Norwood bill, for example, Rep. Greg Ganske, MD (R, Iowa), escorted an Atlanta boy, James Adams, into the chamber. According to Ganske, the boy lost his hands and legs as a result of shoddy HMO handling of a medical emergency.

But for employers and insurers, and many Republicans, the bill would have dire consequences in pushing more health matters into the courts. "It will drive up health care costs and drive up the numbers of the uninsured," said Rep. Ernie Fletcher, MD, (R, Ky.), who backed the Coburn alternative. The Chamber of Commerce blasted the Norwood bill in a statement, saying it would "move medical decision-making to the courtroom, where the only winners are the lawyers."

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."

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