INTRODUCTION OF THE
[Congressional Record: Page E563]
QUALITY HEALTH CARE AND CONSUMER PROTECTION ACT
HON. MARGE ROUKEMA
in the House of Representatives
FRIDAY, MARCH 21, 1997
- Mrs. ROUKEMA. Mr. Speaker, I rise today to introduce the Quality Health Care and Consumer Protection Act of 1997.
- The past several years have seen an increasing and disturbing trend of the health insurance industry putting bottom-line medicine ahead of quality medical care. The evidence is everywhere.
- First were the documented reports that women were being discharged from hospitals 24 hours--even 12 hours--after giving birth. Then came reports of women being shown the door after having outpatient mastectomies. In addition, physicians are barred from telling a patient about a lifesaving or life-improving treatment option or specialized care if it is more expensive than the insurer is willing to pay. Doctors were literally being gagged, in violation of their professional oaths. Men and women are not allowed to call for an ambulance without receiving prior approval from their managed care plan. Enrollee records are not kept confidential.
- These practices, and others, spell an alarming trend in managed care. It would appear that managed care has allowed--or even forced--insurance companies to place company profits ahead of patient care. To many of us, this smacked of third world medicine. Are we to abandon our historical position as the world's leader in medical care?
- As a result, many individual States have started to mandate the coverage that insurers must provide. While I understand the States' desire to protect the quality of care, I am not sure this commonsense regulation is best executed at the State level.
- Congress should go beyond taking these issues on a piecemeal basis and take broad comprehensive action. Consequently, I am introducing the Quality Health Care and Consumer Protection Act. Based on a series of proposals from Women in Government, a bipartisan group of State legislators from across the country, my bill represents a consensus on steps to ensure that managed-care networks provide high-quality, efficient care, not just low-cost care that boosts profits.
- I am aware that there are other health reform plans pending in Congress. My bill, however, goes further because it also includes the millions of American workers whose health plans are regulated under ERISA. ERISA is the Federal law that regulates large corporations that self-insure and these companies would be exempt from the other legislation pending before this House. We must provide the same high standard of quality of medical care for all Americans, not just some.
- This legislation would protect consumers without denying managed care's potential for legitimate innovation and cost control. This measure would return the power over medical decisions to those with the medical training and expertise--the doctors and the nurses.
- Better Access to Personnel and Facilities--Ensures that enrollees are given meaningful choice of available physicians and specialists, which includes reasonable access to acute care hospital services, primary care practitioners, registered nurses, specialists and specialty medical services such as physical therapy and rehabilitative services.
- Continuity of Care--Requires that enrollees are provided continued coverage with the established primary care practitioners for 60 days, when the health care professional's contract is terminated without cause.
- Emergency Service Coverage--Ensures that the health plan reimburse expenses for treatment of an emergency medical condition, when prior authorization was not obtained, if a prudent layperson would reasonably assume that the condition required immediate medical treatment.
- Adequate Choice of Health Care Professionals--Ensures that the health plan permit enrollees to choose their own primary care practitioner from a diverse list of qualified professionals who are accepting new enrollees. In addition, when the enrollee's medical conditions warrant it, the enrollee shall be permitted to use a medical specialist primary care practitioner.
- Point of Service Option--Ensures that the plan have an option for an enrollee to receive benefits by a nonnparticipating health care professional for an additional reasonable premium.
- Prohibition of Gag Rules--Ensures that there is open communication between health care professionals and enrollees.
- Coverage of Drugs and Devices--Requires that a health plan that provides benefits with respect to drugs and medical devices shall provide coverage for all drugs and medical devices approved by the Food and Drug Administration so long as the primary care practitioner or other medical specialist determines the drug or device is medically necessary and appropriate.
- Coverage of Experimental Treatment--If a health plan limits coverage for services, then the plan shall define the limitation and disclose the limits in any agreement of coverage. When a plan denies coverage for an experimental treatment, then the plan shall provide a letter explaining the denial, along with a description of alternative treatment covered by the plan.
- Quality Assurance Program--Requires that the health plan develop comprehensive quality assurance standards which are adequate to identify, evaluate and remedy problems relating to access, continuity and quality care.
- Data Systems and Confidentiality--Ensures that the health plan provide information on the plan's structure, decision making process, health care benefits and exclusions, cost and cost-sharing requirements, list of participating providers as well as grievance and appeal procedures to all enrollees, the Secretary of Labor, and the Secretary of Health and Human Services.
- Reporting of Data--Requires that the health plan report annually to the Secretary of Labor and the Secretary of Health and Human Services data including the number and types of enrollee grievances or complaints during the year, the status of decisions, and the average time required to reach a decision. In addition, the health plan must report the number, amount, and disposition of malpractice claims resolved during the year.
- Medical Records and Confidentiality--Requires that the health plans establish policies and procedures for keeping enrollee information confidential.
- Disclosure about Financial Arrangements--Requires that the health plan inform enrollees of the financial arrangements between the plan or issuer and participating providers and professionals.
- Grievance Procedures--Provides a grievance procedure that all health plans must follow, while also requiring that the plan provide written notification to enrollees regarding the right to file a grievance concerning denials or limitations of coverage under the plan. In addition, the plan shall report to the Secretary of Labor and the Secretary of Health and Human Services the number of grievances and appeals received by the plan.
- Mr. Speaker, managed care has a legitimate role to play in today's health care system. However, no health care system should be allowed to sacrifice patient care on the altar of corporate profits. The Quality Health Care and Consumer Protection Act makes significant steps toward returning medical decisions to doctors and other health care professionals and away from gatekeeper bureaucrats in HMO offices.
- Medical professionals for generations have worked long and hard to give the United States the highest standard of medical care in the entire world. Our physicians, nurses, and medical researchers have performed miracles in combating dreaded disease, repairing ghastly injuries, and correcting infirmities. We cannot allow green-eyeshadded bean counters in insurance company accounting departments to throw that progress away. With a health care system that is the envy of the world, we must not allow the United States of America to slip to third world standards of medicine.