congressional_record: CREC-1994-12-20-pt1-PgE5
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| CREC-1994-12-20-pt1-PgE5 | 1994-12-20 | 103 | 2 | CONSUMER PROTECTIONS NEEDED IN HEALTH MANAGED CARE PLANS | HOUSE | EXTENSIONS | FRONTMATTER | E | E | [{"name": "Fortney Pete Stark", "role": "speaking"}] | 140 Cong. Rec. E | Congressional Record, Volume 140 Issue 150 (Tuesday, December 20, 1994) [Congressional Record Volume 140, Number 150 (Tuesday, December 20, 1994)] [Extensions of Remarks] [Page E] From the Congressional Record Online through the Government Printing Office [www.gpo.gov] [Congressional Record: December 20, 1994] From the Congressional Record Online via GPO Access [wais.access.gpo.gov] CONSUMER PROTECTIONS NEEDED IN HEALTH MANAGED CARE PLANS ______ HON. FORTNEY PETE STARK of california in the house of representatives Tuesday, December 20, 1994 Mr. STARK. Mr. Speaker, managed care represents a threat and an opportunity. The threat is that quality care and innovative treatment will be sacrificed to short-term profit. The opportunity is the potentially wider availability of health care. The tools of managed care--credentialing, case management, control of utilization, innovative use of information systems, and efficiency through total quality management--have been used in an attempt to lower costs through a more rational use of resources. The success of managed care programs is questionable, however, and numerous accounts of abuse in managed care programs are highlighted each day in newspapers, magazines, and scholarly journals.These accounts demonstrate the destructive potential of managed care approaches. The following is a list of concerns extracted from recent articles. This list, combined with emerging data on the effectiveness of managed care programs presents convincing evidence that we are just beginning to understand the ramifications of one of the most dramatic trends in health care--that of managed care. Regulation of the managed care industry is necessary to protect consumers' rights to quality health care. Issues of Concern in Managed Care i. enrollment Agents enroll beneficiaries who do not understand managed care restrictions. Some beneficiaries have been enrolled and re-enrolled in plans dozens of times. This is often known as ``churning of enrollees''. Lock-in provisions are often not explained. Enrollment of the beneficiaries is often done through M.D. offices without complete disclosure to the beneficiary. Reports of mass enrollment by trickery. For example, reports state that citizens were asked to come to a local library to ``practice'' filling out their enrollment forms. The forms were then collected and used to enroll unsuspecting seniors in managed care plans. ii. marketing Selective marketing is sometimes directed toward healthier seniors. Reports that prohibition on marketing practices and fraudulent claims is being violated. Agents may excessively raise expectations of the beneficiary. Ex. agents convincing seniors to switch HMO's using false attacks on competitor, e.g., not enough funds to pay doctors. Out of network coverage can be misleading. For example, a seventy-five year-old woman with a broken hip was expected to travel across the country following initial hospitalization. iii. quality of care Care decisions are often made by inexperienced gatekeepers instead of by on line physicians. Inappropriate denial of procedures that are recommended by a physician and covered by Medicare. Inappropriate delay in providing services/goods which the HMO approved (ex. wheelchair). No professional obligation to the enrollee by the HMO similar to that of the MD/patient or nurse/patient relationship. The lack of professional relationship could limit recourse for appeal by patient. Approved list of drugs (formulary) given to MDs may not include name brands. Difficulty in getting any drug not on the formulary. Quantity of drugs may be limited at the pharmacy so that patients have to make numerous trips to get the drugs for the prescribed number of treatment days. Inappropriate refusal to cover a skilled nursing home or failure to develop a safe plan for patient discharge. Medicare beneficiaries encouraged to disenroll from risk contract HMOs once they get sick. High turnover of HMO physicians. There is a lack of care continuity. Patients are assigned physicians rather than choosing them. There is a need to protect patient confidentiality. For example, software packages for internal outcomes-related criteria are shared with health professionals in managed care plan/hospital not on patient case. Enrollee complaints about waiting for appointments. iv. oversight/regulation There is often no pattern for state regulation of HMOs. There are no uniform state quality assurance requirements. Advocates express frustration at lack of oversight efforts in federal HMO regulation. No uniform national standard requirement for solvency and quality assurance. The split in oversight responsibility at the state level leads to gaps: Insurance departments have oversight over business issues and contracts; Health departments regulate quality of care and credentials of providers; Complaints and ratings are areas of interaction. However, in practice, ratings are primarily dealt with by the Insurance Commissioners. Preferred Provider Organizations (PPOs) are regulated only when they assume risk. There is a lack of uniform comparative information on HMO plans for consumer use. HMOs liability for denial of care may be inappropriately limited. v. provider issues In some cases, there are limited contract termination rights for physicians. There are some reports of limited referrals to specialists in the network when referral is appropriate. Need for more comprehensive utilization review standards. Unclear utilization standards. Difficulties getting prior authorization. Inadequately qualified reviewers. Standards and process differ to every plan. Plan standards and processes constantly changing. No provider input into developing standards. Some managed care plans use a physician's name in a marketing appeal without approval from the physician. Some managed care plans do not notify physicians when they are seeking to create or expand a network. Refusal to reimburse non-network providers for emergency out-of-area services. ``Gag rule'' to limit information providers may give patients regarding alternative treatments (Rep. McDermott). Non-HMO providers pursue patients for bills that are the responsibility of the HMO. Some HMOs may hire ``problem'' physicians. Providers rate/evaluated based on their cost of practice procedures (referrals/ tests/hospitalizations). vi. grievance procedures/due process Review by an HMO may take as long as the HMO wants to extend it--time works against the elderly sick. Failure of HMOs to meet requirements of notice of right to appeal. Beneficiary needs notice of the right to submit independent information to support his position when a treatment is denied. Beneficiary may be denied care without being shown the information on which the decision was made. No paperwork means no notice of how benefits, particularly drug benefits, are calculated. There is often no notice to the beneficiary that the drug benefit limit is fast approaching so that seniors can budget for payments that will be inevitable. Wholesale drug price the HMO uses to calculate benefit may exceed retail cost at other pharmacies. In many cases, there is no immediate access to an independent peer review authority. There is no right to have representation at appeal. Medicare beneficiary appeals take too long to resolve--4 to 6 months on average. No advocates for the consumer in the HMO. Beneficiaries have problems getting reimbursed for out-of- area emergency services. ____________________ |