Has the House helped you?
By Congressman John D. Dingell

The House passed managed care reform legislation -- sort of -- last Friday. The problem is solved, patients can rest easy, and the House can coast for the rest of the 105th Congress, basking in adulation from... well, from whom?

The National Federation of Independent Business was the lone organization to endorse the legislation the House passed Friday. In hosannas to the House, the NFIB most certainly will not be joined by the more than 170 consumer, doctor, provider, senior citizen and labor organizations who endorsed the competing Patients' Bill of Rights, which failed by five votes.

If you, anyone in your family, anyone you know, or anyone you're familiar with faces circumstances similar to the following examples, you stand to be severely disappointed by your lack of rights if the so-called Patient Protection Act passed by the House is eventually signed into law.

Here's who won't be helped, and how they would be helped by the Ganske-Dingell Patients' Bill of Rights:

Example one: The mother of a child with leukemia wants the child's pediatrician to decide what care her child needs.

The Republican bill allows the health insurance plan, not the doctor, to determine what treatment is medically necessary. The Patient's bill of rights would allow the pediatrician to make these treatment decisions on the basis of good medical practice, not generally accepted accounting principles.

Two: A terminally ill cancer patient has no other treatment available to save his life. The doctor recommends a clinical trial.

The Patients' Bill of Rights gives access to paid and approved clinical trials and requires the health plan to pay for "routine patient costs" for items and services furnished in connection with participation in the trial. The Republican bill gives nothing.

Three: A woman is in her second trimester of pregnancy when her doctor is dropped from the health plan.

The Patients' Bill of Rights allows a woman to keep seeing her doctor through delivery and for post-partum care (as long as there are no quality or fraud problems with the doctor). The Republican bill would make her get a new doctor.

Four: A little girl suffers from a chronic ear infection. The only drug on the plan formulary to treat ear infections does not work for her. The Patients' Bill of Rights would allow doctor to prescribe a drug off the formulary that works. The Republican bill would do nothing.

Five: A man has severe pain and thinks he has a heart attack. He drives to the closest hospital, but the hospital does not participate in the health plan.

The Patients' Bill of Rights would allow him to go the emergency room without prior authorization at no extra cost. Severe pain qualifies under the prudent layperson standard. (He would also be eligible post-stabilization care, and would not be discharged to another hospital before his doctor said he was ready.) The Republican bill would allow the plan to charge the patient more for going to a nonparticipating hospital without prior authorization. Severe pain does not qualify for an emergency visit if it turned out that the man was not having a heart attack, and the Republican bill would let the plan deny payment for the whole visit. The Republican bill would also allow the plan to force the patient to be moved to another hospital after the emergency screening was conducted, or refuse to pay for any stabilization care in the non-participating hospital.

Six: A woman with breast cancer has a mastectomy.

The Patients' Bill of Rights allows her to stay in the hospital for up to 48 hours, if the doctor and the woman agree it is needed. The Republican bill would allow health plans to send her home that very day, regardless of what the doctor thought was the best treatment.

And if the woman requires radiation therapy following her mastectomy? The Patients' Bill of Rights would allow her oncologist to make these referrals for the required number of visits. The Republican bill would allow health plans to make the woman go back to the primary care doctor each time she needed to get these treatments.

Seven: A child with cancer needs to see an pediatric oncologist to treat her disease. The health plan only has an adult oncologist.

The Patients' Bill of Rights allows the child to go out of network at no extra cost to an appropriate specialist. The Republican bill would not even guarantee the child access to an adult oncologist, let alone a specialist with appropriate expertise to treat children's needs.

Eight: A man with a stroke requires follow up visits to a physical and speech therapist to regain functioning.

The Patients' Bill of Rights would allow him to get a standing referral to see the therapist for the required number of visits. The Republican bill would allow the health plan to make the man go back to the primary care doctor each time he needed to go to the therapist.

Nine: A pregnant woman's doctor believes she needs round the clock nursing care in her last month of pregnancy to prevent her from losing her fetus. The health plan says it is not medically necessary.

The Patients' Bill of Rights would allow the doctor to determine what care was medically necessary. The Republican bill would allow the managed care plan to determine the definition of medically necessary care. Under the Republican bill, she could not even file a meaningful appeal of the plan's decision, because the appeal is based only on whether the plan followed its own definition of medical necessity, not whether the service was actually medically necessary. If the woman lost her child as a result of not having the nursing care, under the Republican bill, she would be able to go to federal court to get back the cost of the nursing care that the plan didn't provide, even though she had just lost her baby. The penalty on the health plan would only be $500 per day with a cap of $250,000.

Ten: A doctor advocates for medically necessary care for his patient. The plan fires him.

The Patients' Bill of Rights protects doctors and nurses who advocate on behalf of their patient. The doctor would be able to file a complaint against the plan, and get his job back, if this were the only reason he was fired. The Republican bill allows health plans to continue firing doctors and nurses who do their jobs.

Eleven: A health plan pays its doctors bonuses when they keep the number of referrals or prescriptions written to a low number, regardless of whether or not the care or drug was necessary.

The Patients' Bill of Rights prohibits health plans from paying doctors not to give needed care. The Republican bill allows health plans to continue this practice.

Twelve: A person enrolled in an association health plan through the employer wants to file a complaint about the plan.

Under the Patients' Bill of Rights this person would have full appeal rights. The Republican bill takes away the right to file a complaint under state law (because it preempts state regulatory authority in this area).

Thirteen: A person has a chronic condition and requires large numbers of prescription drugs.

Under the Patients' Bill of Rights any existing Federal and State laws prohibiting pharmacies from sharing these records with insurance companies would stay in place. The Republican bill would allow the pharmacy to share all of its records with an insurance company "for underwriting and experience rating" purposes, allowing the insurance company to decide who to cover. As soon as doctors or pharmacists are allowed to release private records, managed care plans can require them do to so as a condition of participating

Fourteen: A man has been diagnosed with prostate cancer and doesn't want anyone else to know.

Under the Patients' Bill of Rights any existing Federal and State laws which require notification or consent from the patient prior to release of this information would stay in place. The Republican bill preempts State laws and would allow these disclosures to take place with no patient notification or consent. Nothing would prohibit the plan from redisclosing the information they gather to anyone for any purpose.

The fifteenth, and final (for now) example: A woman has signed up for a health plan whose enrollment brochure says it provides one free preventative exam a year. Halfway through the year, the health plan decides to change and not cover this service.

Under the Patients' Bill of Rights the health plan would have to notify the patient prior to the effective date of the change. The Republican bill allows health plans to make this change without prior notification to the enrollee.

These are fifteen good reasons (of literally millions) why the Senate should pass real patient rights legislation, and why the President should withhold his signature from any bill that does less than the Patients' Bill of Rights.

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