A True Bipartisan Compromise Protecting Patients


About 200 provider and patients rights groups agree that the bipartisan McCain-Edwards-Kennedy Patients Bill of Rights, which has a majority of support in both the Senate and the House, is the only patients rights legislation currently under consideration that assures patients the protections they need.
 
 
It guarantees access to needed health care specialists; requires continuity of care protections so that patients will not have to change doctors in the middle of their treatment; provides access to a fair, unbiased, and timely internal and independent external appeals process to address health plan grievances; assures that doctors and patients can openly discuss treatment options; and includes an enforcement mechanism that ensures these rights are real.
 

The bipartisan McCain-Edwards-Kennedy compromise:


Protects all Americans in all health plans. All of the comprehensive protections in this bipartisan compromise legislation apply to all Americans in all health plans. No person is left without rights because the state they live in has weaker protections. However, this legislation allows states to develop stronger patient protections and allows governors to assure that substantially equivalent protections remain intact.
 

Ensures a swift internal review process and a fair and independent external appeals process. This bipartisan compromise outlines reasonable criteria and time frames for initial claims review and internal appeals procedures. It also creates a timely and independent external review process that assures individuals a fair and unbiased decision. When patients have medical emergencies, the review process can be expedited. Neither party can select the external review entity and neither can unilaterally delay the review process by withholding needed information. Reviewers are free to make an independent determination about whether care is needed and are not bound by plan decisions or policies. And patients have legal recourse if the managed care plan does not comply with the decision of the external review entity.

 
Protects employers against liability. This bipartisan compromise legislation clearly states that employers cannot be held responsible for the actions of managed care companies unless they actively made the decision to deny a health care service to a patient. It ensures that only those few companies (less than 5 percent nationwide) that act as health care insurers and directly participate in the decision to deny a health care benefit to a patient accept legal responsibility.

Allows patients to hold their managed care plan accountable when plan decisions to withhold or limit care result in injury or death. This bipartisan compromise allows patients to seek redress in court for any wrong that causes an injury. Patients rights without a real remedy is no right at all. The liability compromise in McCain-Edwards-Kennedy stems from recent Supreme Court decisions as well as concerns voiced by employers on the importance of federal uniformity when administering health plans. It tracks the Supreme Court decision in Pegram vs. Herdrich, which stated that cases concerning medical judgment should be heard in state court, but ensures that employers and insurers can uniformly administer their plans across the country by putting those cases concerning administrative decisions in federal court.
 
Exhaustion required before moving to court. Patients must always exhaust internal and external appeals before going to court. The sole exception is when death or irreparable injury has already occurred. Even in that case, either party can request the appeals process to continue and the results of the process be considered in court.

Guarantees access to necessary specialists -- even if it means going out of the plans provider network. The bipartisan compromise requires plans to allow patients access to non-participating providers if the plans network is insufficient for the enrollees needs. Under these limited circumstances the plan must provide this access at no greater cost than if the benefit were obtained from participating providers. This provision ensures access while maintaining the integrity of health plan networks.
 
Ensures that chronically ill patients receive the specialty care they need. Patients shouldn't have to fight their health plan at the same time they are fighting an illness. This bipartisan compromise legislation ensures that persons with life-threatening, degenerative, and disabling conditions can access standing referrals to specialists, so their primary care provider does not have to continue to authorize visits. In addition, this bill requires plans to allow such persons to designate a specialist as their primary care provider if the specialist could better coordinate their care.
 
Ensures that patients can access emergency room care where and when the need arises. This bipartisan compromise legislation ensures that patients can receive critical emergency room care from any emergency department, in or out of the plans network and without prior authorization under the Òprudent laypersonÓ standard. This means that if the patient believes they need emergency care, they can go to any emergency room without worrying about excessive cost sharing requirements and are guaranteed a smooth transition between emergency care and follow-up treatment provided by the plan.
 

Ensures that women can easily access OB-GYN services, without unnecessary barriers. This bipartisan compromise ensures that women can choose an OB-GYN as their primary care provider. It also allows women to obtain routine ob-gyn care from a participating health care professional who specializes in obstetrics and gynecology without prior authorization or referral.
 
Ensures that children can access the specialty care they need, without unnecessary barriers. This bipartisan compromise ensures that pediatricians can be selected primary care providers for children.
 
Ensures that patients can access the prescription drugs that are prescribed for them. Under this bipartisan compromise, physicians and pharmacists must participate in formulary development. Plans must provide for exceptions from the formulary when medically indicated. This protection is critical for individuals who may have allergies to certain medicines or may have tried the formulary drug without any success. Formulary restrictions must be disclosed to enrollees and providers on request.
 
Ensures that patients can participate in potentially life-saving clinical trials. Under this bipartisan compromise, plans must cover routine costs (those costs of treatment that would normally be covered by the plan) of participation in certain clinical trials if the patient has a life-threatening or serious illness for which no standard treatment is effective and participation in the trial offers meaningful potential for significant clinical benefit. This is an important protection for patients with Alzheimers, cancer, or other diseases where there is no cure.
 
Ensures continuity of care for patients with ongoing health care needs. This bipartisan compromise legislation protects all patients who are in the middle of a course of treatment for a chronic or disabling condition, ensuring that they can keep their doctor even if they are forced to changed plans or their doctor is dropped from their plans network. It requires a transitional period during which they will continue to receive care from the treating provider.

Makes sure that people have the information they need about their health plan benefits. Patients need to know about their health plan rules before they seek care. The detailed disclosure requirements that are part of this bipartisan compromise to assure patients understand their rights include: plan benefits, limitations and exclusions; how out-of-network services are covered; how to select and obtain referrals to providers; emergency medical care coverage and definitions; prior authorization rules; and grievance and appeals procedures.

Anti-gag rule protections



This legislation would assure that health plans cannot prevent doctors and nurses from discussing all treatment options with their patients. Limiting improper incentive arrangements. This legislation also ensures that doctors will not face excessive financial incentives limiting necessary care. Protections for patient advocacy. This legislation protects health care providers from the threat of retaliation or firing when they advocate on behalf of their patients or report quality issues to the appropriate regulatory agencies.